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http://www.archive.org/details/manualofprinciplOOsmit 


MANUAL 


OF    THE 


PRINCIPLES  AND  PRACTICE 


OF 


Operative  Surgery. 


STEPHEN   SMITH,  A.  M.,  M.  D., 

SURGEON  TO  BELLEVUE   AND  ST.  VINCENT  HOSPITALS,  NEW  YORK 


BOSTON: 

HOUGHTON,  MIFFLIN  AND   COMPANY. 

NEW   YORK  :    21    ASTOR   PLACE. 

([n)t  EtberatTie  Pregg,  CambrtUfft. 

188L 


Copyright,  1879, 
Bt  STEPHEN   SMITH. 

All  rights  reserved. 


'(^H  32. 


9 


RIVERSIDE,  CAMBRIDGE: 

ELECTROTTPED    AND    PRINTED     BI 

H.   0.  HOUGHTON  AND  COMPANY. 


PEEFAOE. 


The  Handbook  of  Surgical  Operations,  prepared  by  the  writer 
in  18G2,  though  specially  designed  for  military  practice,  was  received 
with  much  favor  by  the  profession  at  large.  The  request  has  often 
been  made,  by  both  medical  practitioners  and  students,  that  the  plan 
of  the  work  should  be  enlarged  so  as  to  include  the  general  operations 
of  surgery  in  civil  practice.  The  present  work  is  the  result  of  an  ef- 
fort to  realize  that  object  within  the  limits  assigned,  namely,  general 
operations  in  surgery,  the  organs  of  special  sense  being  excluded. 
The  arrangement  of  matter  and  the  structure  of  the  text  require 
explanation  :  (1.)  In  defining  the  qualifications  of  the  surgeon  no 
attempt  is  made  to  establish  an  ideal  standard  of  excellence.  On 
the  contrary,  the  true  estimate  of  his  qualifications  is  found  in  the 
civil  obligation  which  he  assumes  whenever  he  undertakes  the  care 
of  any  case.  The  judicious  discrimination  which  the  common  law 
makes  of  the  relation  of  qualifications  to  time,  place,  and  circum- 
stances, are  far  more  important  than  have  ever  been  defined  by 
any  professional  code.  (2.)  It  follows  that  as  conformity  to  the  es- 
tablished principles  of  an  art  is  a  fundamental  requirement  of  the 
civil  obligation  upon  those  who  practice  such  art,  a  manual  of  this 
character  should,  as  far  as  practicable,  illustrate  those  principles. 
It  has,  therefore,  been  a  constant  effort  to  give  to  the  text  the  high- 
est degree  of  authority,  by  embodying  the  teachings  of  recognized 
authorities  on  every  subject,  so  far  as  they  conform  to  what  is  be- 
lieved to  be  the  present  standard  of  surgical  opinion  and  practice. 
And  to  the  same  end  the  various  subjects  have  for  the  most  part  been 
submitted  for  revision  to  competent  authority  and  receive<l  its  sanc- 
tion; where  special  importance  is  attached  to  such  revision,  the  name 
of  the  person  consulted  appears  in  small  capitals.  New  theories 
and  methods  are  noticed  in  the  leading  text  only  so  far  as  they  are 


IV  PREFACE. 

obviously  correct,  or  are  sanctioned  by  the  weight  of  responsible 
names.  (3.)  In  order  to  economize  space,  the  opinions,  and,  as  far 
as  practicable,  the  language  of  writers,  have  been  incorporated  into 
a  condensed,  uniform  text,  due  credit  being  given  by  marginal  ref- 
erences to  the  names  of  authors.  The  larger  type  is  designed  to 
embody  the  principles  and  practice  now  established  by  authority, 
whilst  the  smaller  type  is  employed  for  explanatory  or  su])plemental 
matter. 

In  the  general  treatment  of  subjects  something  more  has  been 
attempted  than  to  give  the  mere  formal  details  of  operations.  Forty 
years  ago,  the  author  ^  of  the  most  popular  and  useful  manual  of 
operative  surgery  ever  issued,  remarked  in  the  preface,  that  such  a 
treatise,  to  satisfy  all  the  requirements  of  the  age,  should  for  each 
operation  discuss  indications,  exactly  study  the  surgical  anatomy, 
review  all  the  proceedings,  and  after  mature  examination  and  judi- 
cious choice  of  the  best,  describe  the  manipulation  with  all  the  neces- 
sary details,  point  out  the  different  methods  of  dressing,  give  a  sta- 
tistical account  of  successes  and  failures,  and,  finally,  in  autopsies 
seek  the  causes  of  death  in  fatal  cases.  Although  it  is  quite  im- 
possible, in  the  limited  space  of  a  manual,  to  discuss  these  and  the 
many  new  questions  relating  to  operations,  yet  the  suggestions  of 
that  eminent  author  have  been  constantly  borne  in  mind,  and  as  far 
as  practicable  followed.  No  stereotyped  method  of  treating  sub- 
jects has  been  pursued,  but  each  has  been  considered  in  such  man- 
ner as  seemed  best  adapted  to  present  all  necessary  facts  in  the  most 
available  form  for  the  practitioner. 

The  illustrations,  though  ordinary  in  kind,  form  an  important  fea- 
ture of  the  work.  They  were  selected  for  the  purpose  of  illustrating 
special  features  in  each  case,  and  only  such  parts  have  been  used  as 
were  essential  for  that  object.  They  have  been  derived  from  many 
sources,  as  from  the  former  work,  from  works  on  surgery,  medical 
periodicals,  and  from  manufacturers  of  instruments.^  A  large  num- 
ber were  specially  drawn  for  the  work,  some  of  which  are  original 
studies  of  the  artist.^  Due  credit  is  given,  as  far  as  possible,  to  the 
source  from  which  each  was  derived. 

1  J.  F.  Malgaigne. 

2  Tiemann  &  Co.;  Reynders  &  Co.;  Codman  &  Shurtleff. 

3  W.  C.  W.  Glazier,  M.  D. 


COi^TENTS. 


I. 

THE    PRINCIPLES. 


CHAPTER 

I.  —  The  Obi-ioation  . 
II.  —  Thk  Kxamination    . 

III.  —  TlIK    I'KKrAKATIDN 

IV.  —  The  H.emohuhage  . 
V.  —  The  Ax.E-sTirEsiA 

YI. — The  Oi'ERATioN 
VII.  —  The  Kmeisgexcies 
VIII. — The  Dkessing  . 

IX.  — The  Ai-1'i.iAxcEs  . 
X.  —  The  Kei'aik 

XI.  —  The  CiCAxaiZATiON 


PAGE 

1 
5 
11 
17 
26 
31 
34 
39 
50 
56 
73 


II. 

THE    OSSEOUS    SYSTEM. 

THE   BONES;   THE   JOINTS. 

XII.  —  The  Ixjukies  of  Boxes 80 

XIII. —I>isEA.sEs  OF  B<)XE  AND  Special  Operations         .  .    101 

XIV. — General  Operations  on  the  Bones    ....  Ill 

XV.  —  Injuries  of  Joints  and  Special  Operations       .  .    147 

XVI.  —  Diseases  of  the  Joints  anu  Special  Operations   .  154 

XVII.  —  General  Operations  on  the  Joints       ....  168 


III. 

THE    MUSCULAR    SYSTEM. 

THE  MUSCLES;  THE  TENDONS;  THE  FASCI.5: ;  THE 
BUKS.E. 

XVIII.  — IX.HRIES    OF   THE    MCSCULAR    SYSTEM,     AND    SPECIAL   OP- 
ERATIONS          193 

XIX.  —  Diseases  of  the  Muscular  System,  and  Special  Op- 
erations   196 

XX.  —  General  Operations  ox  the  Muscular  System     .  202 


vi  CONTENTS. 

IV. 
THE    CIRCULATORY    SYSTEM; 

THE   HEART;   THE    ARTERIES;   THE    CAPILLARIES;    THE 
VEINS;   THE   LYMPHATICS. 

XXI.  —  The  Injuries  of  the  Circul.^tory   System  and  Spe- 
cial Operations 213 

XXII. — Diseases   of  the    Circulatory    System  and    Special 

Operations  220 

XXIII.  —  General  Operations  on  the  Circulatory  System    .    232 

V. 

THE   NERVOUS   SYSTEM.. 

THE  BRAIN;   THE   SPINAL   CORD;   THE   NERVES. 

XXIV.  —  Injuries  of  the  Nervous  System,  and  Special  Oper- 

ations        275 

XXV.  —  Diseases  of  the  Nervous  System  and  Special  Oper- 
ations      283 

XXVI.  —  General  Operations  on  the  Nervous  System  .        .    291 

VI. 

THE   TEGUMENTARY   SYSTEM. 

THE   SKIN;   THE   HAIR   AND   GLANDS;   THE   NAILS. 

XXVII.  —  Injuries  of  the  Tegumentary  System  and   Special 

Operations 302 

XXVIII.  —  Diseases  of  the  Tegumentary   System  and   Special 

Operations  313 

XXIX.  —  General  Operations  on  the  Tegumentary  System    .  325 

VIL 
THE   DIGESTIVE   ORGANS. 

XXX.  —  The  Lips 340 

XXXI. —The  Palate 350 

XXXII. — The  Alveolar  Process;   The  Salivary  Glands;  The 

Tonsils 358 


CONTENTS. 

Vll 

XXXIII. 

—  The  Tongue 

.        367 

XXXIV. 

—  The  Phauy.nx;  The  CEsophagus 

.    375 

XXXV. 

—  The  Stomach 

381 

XXXVI. 

—  The  Ulodexum;  The  Jejunum;  The  Ileum  . 

.     388 

XXXVII. 

—  The  Cecum;  The  Colon        .... 

39C 

XXXVIII. 

—  The  Kkctum 

.    405 

XXXIX. 

—  The  Anus 

410 

XL. 

—  The  LiVKii;  The  Spleen    .        .        .        .        • 

.    426 

XLI. 

—  The  Abdomen 

4.>1 

XLII. 

—  The  Hekni.e  of  the  Abdomen 

.     436 

VIII. 
THE    RESPIRATORY   ORGANS. 

XLIII.  —  The  Nose:  The  Nasal  Foss.e;  The  Antkum        .  .    4.>5 

XLIV.  —  The  Lakynx 470 

XLV. — The  Thachea;  The  Thyroid  Body;  The  Bhonchi  .    483 

XLVI.  —  The  Lungs 490 


IX. 


THE  URINARY   ORGANS. 

XLVII.  —  The  Kidneys 497 

XLVIII.  —  The  Urinary  Bladder 502 

XLIX. —The  Urethra 527 


X. 


THE   GENERATIVE   ORGANS. 


THE    MALE   ORGANS. 


L.  —  The  Testicles     . 
LI.  —  The  Prostate  Gland 
LI  I.  —  The  Penis    . 


545 
552 
555 


THE   FEMALE   ORGANS, 


Lin. —The  Ovaries 
LIV.  —  The  Utet.us 
LV.  —  The  Vagina 
LVL  —  The  Vulva       . 
LVII.  —  The  Mammary  Glands 


559 
506 
571 
576 
585 


viii  CONTENTS. 

XL 
THE    EXTREMITIES. 

LVIII.  —  Amputation 590 

LIX.  —  Deformities 633 

LX.  —  Compensative  Appliances 649 

INDEX 663 


OPERATIVE    SURGERY. 


I. 
THE   PRINCIPLES. 


CHAPTER    I. 

THE  OBLIGATION.! 

The  Principles  of  an  art  are  those  general  truths  and  maxims 
which  competent  authority  has  established.  If  an  art  is  progressive, 
like  operative  surgery,  the  principles  cannot  all  be  fixed  and  perma- 
nent, but  must  change  with  the  advance  of  scientific  improvements. 
These  changes  take  place  gradually,  for  alleged  new  truths  do  not 
obtain  the  weight  and  importance  of  principles  until  they  have  re- 
ceived the  sanction  of  recognized  authority.  In  order  to  determine, 
therefore,  the  principles  of  an  art  suscei)tible  of  constant  improve- 
ment, it  is  necessary  to  consult  the  o|)inions  of  its  acknowledged 
exponents  at  the  particular  period  under  review.  An  adequate 
knowledge  of  the  principles  of  operative  surgery,  as  thus  estab- 
lished, is  a  part  of  the  civil  obligation  of  the  surgeon,  for  the  stand- 
ard of  judicial  estimation  of  his  responsibilities,  in  any  case,  is  an  in- 
telligent application  of  those  i)rinciples  in  practice. ^  And  the  same 
criterion  is  required  by  the  professional  obligation.  But  this  meas- 
ure of  success  implies  special  qualifications,  for  though  capital  opera- 
tions are  attended  with  a  certain  degree  of  risk  to  life,  and  the  minor 
or  insignificant  may  have  a  fatal  issue  from  causes  which  are  not 
always  easily  determined, »  it  is  nevertheless  true  that  the  results 
of  operations  depend  largely  upon  the  capacity  and  qualifications 
of  the  surgeon.*  Whoever  undertakes  to  practice  any  art  or  pro 
fession  assumes  an  obli'j;ation,  both  civil  and  professional,  whicli. 
though  implied,  has  all  the  force  and  validity  of  a  formal  contract. ^ 
In  legal  construction,  this  obligation  retpiires  that  every  practitioner  of 
operative  surgery  shall,  (1)  possess  that  decree  of  knowledge,  skill. 
and  experience  which  is  ordinarily  possessed  by  the  professors  of  the 

1  Hon.  M   R.  Waitk,  Chief-.Iiistice.  U.  S.  -  Espinasse. 

3  S.  D.  Gross.  *  C.  St'-dillot.  5  Justice  Tvndall. 


2  OPERATIVE  SURGERY. 

same  art  or  science;  and  which  is  regarded  by  those  conversant  with 
that  employment  as  necessary  and  sufficient  to  qualify  bim  to  engage 
in  its  practice  ;  (2)  that  he  use  reasonable  and  ordinary  care  in  the 
exercise  of  his  skill  and  the  application  of  his  knowledge  to  accom- 
plish the  purpose  for  which  he  was  employed ;  (3)  that  he  use  his 

best  iudgment.^ 

I.  QUALIFICATIONS. 

The  measure  of  qualifications  which  the  surgeon  must  bring  to 
the  discharge  of  his  duties  is  defined  to  be  competent  knowledge  of 
the  principles  of  the  art  and  adequate  skill  in  the  application  of  that 
knowledge.  But  there  can  be  no  fixed  limit  to  these  qualifications, 
for  the  required  knowledge  and  skill  rise  in  proportion  to  the  value 
and  delicacy  of  the  operation.''^  Every  case  necessarily  has  its  own 
peculiarities,  and,  therefore,  there  can  be  no  universal  standard  of 
treatment  established. ^  Even  the  most  trivial  operation  is  liable  to 
serious  complications,  requiring  for  its  successful  management  a  wide 
range  of  knowledge,  a  high  order  of  skill,  and  the  largest  experi- 
ence. Recent  judicial  decisions  and  legal  opinions  have  more  dis- 
tinctly defined  these  qualifications. 

1.  The  knowledge  required  is  that  reasonable  degree  of  learning 
which  is  ordinarily  possessed  by  others  of  the  profession  ;*  or  the  req- 
uisite knowledge  to  enable  the  surgeon  to  treat  such  cases  as  he  un- 
dertakes with  reasonable  success,  or  understandingly  and  safely ;5 
or,  again,  he  must  have  that  degree  and  amount  of  knowledge  of  the 
science  which  the  leading  authorities  have  pronounced  as  the  result 
of  their  researches  and  experience  up  to  the  time,  or  Avithin  a  rea- 
sonable time,  before  the  issue  or  question  to  be  determined  is  made.^ 
It  follows  from  those  decisions  that  the  surgeon  who  fully  complies 
with  the  obligation  must  have  adequate  knowledge  of  the  medical 
sciences,  anatomy,  physiolog}-,  and  pathology,  and  of  the  practical 
branches,  medicine,  surgery,  obstetrics,  and  therapeutics.  He  must 
also  be  familiar  with  the  current  opinions  of  the  leading  authorities, 
for  as  surgery  is  a  progressive  science  his  patient  is  entitled  to  the 
benefits  of  new  discoveries. '^  "Without  such  knowledge  no  case  can 
be  treated  understandingly  and  safely. 

2.  The  skill  implied  in  the  contract  is  the  ordinary  skill  of  the 
profession  ^  or  a  reasonable,  fair,  and  competent  degree  of  skill. ^  Tlie 
lowest  grade  of  qualification  which  is  now  regarded  as  admissible 
is  the  least  amount  of  skill  compatible  with  a  scientific  knowledge 
of  the  healing  art.^  But  skill  in  operative  surgery  requires  ifianual 
dexterity.     The  success  of  the  operation  may  depend  upon  the  dex- 

1  Leighton  v.  Sar^ceant.  2  Bonvier.  3  j.  Ordronaux.  *  Rranner  i:  Stormont. 
5  Patten  v.  Wtgc'in.  6  J.  J.  Elweli.  '  McCandless  v.  McWha.  8  Justice  Story. 
9  Justice  Tvndall. 


THE   OBLIGATION.  3 

terity  of  the  surjieon  alone,  when  he  must  employ  the  skill  reqnis^ite 
to  aecomplish  it;^  but  if  the  operation  is  a  part  of  the  general  treat- 
ment of  the  ease,  the  de<p'ee  of  manual  dexterity  must  be  equal  to 
that  exercised  by  other  surgeons  at  the  time  and  in  the  place  where 
tjie   act   is  performed.'^ 

II.  CARE. 

The  degree  of  care  bestowed  on  each  case  must  be  such  as  sur- 
geons of  common  prudence  would  emj)loy.3  There  is  no  standard  of 
comparison  by  wliicli  to  determine  what  is  ordinary  or  reasonable 
care,  but  each  individual  case  must  stand  upon  its  own  merits.'*  In 
the  care  of  any  case  the  surgeon  nmst  conform  to  established  prece- 
dent, ami  lie  diligent  in  the  apjdication  of  remedial  measures. 

1.  Conformity  to  established  rules  of  practice  has,  from  the  ear- 
liest periods,  been  rigidly  exacted.  It  is  held  that  any  deviation  from 
the  established  practice  shall  be  deemed  sufficient  to  charge  the  sur- 
geon with  malpractice,  in  case  of  an  injury  arising  to  the  patient.* 
This  rule  is  designed  to  protect  the  community  against  reckless  ex- 
periments, while  it  admits  the  adojjtion  of  new  remedies  and  modes 
of  treatment  only  when  their  benefits  have  been  demonstrated,  or 
where,  from  the  necessity  of  the  case,  the  surgeon  must  be  left  to  the 
exercise  of  his  own  skill  and  experience.'' 

2.  Diligence  in  the  care  of  a  case  is  the  faithful  application  of 
knowleilue  and  skill.  The  possession  of  the  requi>ite  qualifications, 
and  failure  to  employ  them  sedulously  for  the  benefit  of  the  patient, 
is  nefflifcnce,  and  negligence  is  as  much  a  fraud  upon  the  employer 
as  want  of  skill,  for  it  is  upon  the  diligent  application  of  skill  that 
the  problem  of  success  must  rest.''  It  is  held  that  whenever  any  im- 
portant step  in  the  treatment  of  disease  is  neglected,  or  any  impor- 
tant staije  of  it  is  overlooked  which  might  have  been  used  for  the 
benefit  of  the  patient,  then  it  may  be  averred  that  the  surgeon  has 
been  guilty  of  negligence.'' 

III.  GOOD  JUDGMENT. 

In  everv  case,  good  judgment  must  characterize  the  professional 
acts  of  the  surgeon.  By  good  judgment  is  understood  judgment  bast-d 
upon  a  knowledge  of  the  medical  sciences.*  There  are  few  diseases 
where  a  single  course  of  treatment  can  be  adopted;  in  general,  <iiffer- 
ences  of  opinion  must  exist  as  to  the  best  course  to  be  taken.®  Good 
judament  wisely  determines  the  course  to  be  pursued,  and  applies 
appropriate  means  to  secure  given  results.     Hence  it  follows,  good 

1  Ohio  case.  2  jjaire  r.  Reese.  '  Cater  t'.  Fernald.  *  Ililliard.  5  Kspinasse. 
«  Carpenter  r.  Ulake.  "  J.  Ordronaux.  8  Courtney  f.  Henderson. 

9  LeiL'hton  v.  Sargeant. 


4  OPERATIVE  SURGERY. 

judfinent  and  manual  dexterity  are  essential  elements  in  the  prac- 
tice of  operative  surgery.  Though  both  are  important,  they  are 
not  equally  so;  good  judgment  in  the  selection  and  employment  of 
remedial  measures  excels  manual  skill  in  effecting  favorable  residts  in 
cases  where  both  are  required. ^  When  ha])pily  combined  in  the  same 
person  they  give  the  highest  measure  of  success.  But  as  these  quali- 
ties are  susceptible  of  unlimited  improvement  by  culture,  the  sur- 
geon is  culpable  who  does  not  attain  to  that  degree  of  skill  which  the 
civil  obligation  exacts. 

IV.  RESPONSIBILITY. 

The  civil  obligation  imposes  important  individual  responsibilities 
upon  the  surgeon.  He  must  exercise  his  best  skill  and  judgment  in 
every  case.'^  And  wherever  great  and  extraordinary  skill  is  pos- 
sessed, causing  his  employment  exclusively  on  that  account,  he  must 
bestow  it  to  the  full  measure  of  his  ability,  since  the  exceptional  de- 
gree of  that  skill  is  the  moving  consideration  to  his  employment. ^ 

The  responsibility  also  for  the  success  of  every  operation  which 
he  performs  is  individual.  He  may  decline  to  undertake  any  case,^ 
but  having  accepted  the  trust,  he  alone  is  responsible  for  the  re- 
sults of  treatment.'*  Neither  the  attending  physician,  nor  the  con- 
sulting surgeon,  assumes  any  portion  of  the  obligation.  Through- 
out the  entire  case  the  conduct  of  the  surgeon  must  be  character- 
ized by  fidelity  to  the  patient,  and  a  uniform  and  consistent  appli- 
cation of  skill  in  the  treatment  of  the  disease.  Failure  at  any  time 
to  meet  the  ordinary  indications  in  the  case  vitiates  the  entire  at- 
tendance, for  the  obligation  is  continuous  to  the  termination.^  In 
view  of  these  facts,  it  is  important  that  the  surgeon  should  make 
every  case  which  he  undertakes  peculiarly  bis  own.  He  should  fore- 
cast every  possible  source  of  failure,  and  be  prepared  for  every  possi- 
ble emergency,  for  he  is  the  most  ready  to  take  responsibilities  and 
to  bear  them  lightly  who  can  best  estimate  what  are  the  risks  and 
difficulties  which  he  is  to  incur. ^  In  diao-nosis,  prognosis,  operation, 
and  after  treatment,  his  opinions  should  be  formed,  and  his  course 
of  procedure  marked  out  and  followed,  without  being  unduly  influ- 
enced by  the  solicitation  of  patient  or  friends,  or  the  sugirestions  of 
consultants.  Every  step  should  be  taken  with  that  painstaking  care 
and  deliberation  which  leaves  no  ground  for  a  charge  of  ignorance, 
negligence,  or  want  of  skill.  Thus  the  surgeon  not  only  fulfills  the 
just  requirements  of  the  obligation,  civil  and  professional,  but  se- 
cures that  confidence  and  self-reliance  in  every  stage  of  progress  and 
in  ever)^  emergency  so  necessary  when  great  responsibilities  are  as- 
sumed. 

1  J.  Ashurst,  Jr.  '■'  Paten  v.  Wigjiin.  ^  j.  Ordronaux  :  .J.  J.  Evvell. 

*  F.  C.  Skey.  5  Bellinger  v.  Craigue.  6  Sir  J.  Paget. 


THE  EXAMISATIOX.  5 

CHAPTER  II. 

Tin:  EXAMINATION. 

In  onk-r  to  form  a  judgment  which  will  guide  to  the  proper  treat- 
ment of  any  case  involving  the  question  of  an  operation,  there  must 
first  be  a  systematic  examination  as  to  the  nature  of  the  disease,  the 
condition  of  the  patient,  and  of  all  the  circumstances  favorable  or 
unfavorable  to  success.  AVhile  it  is  true  that  the  unfavorable  issue 
of  cases  may  come  of  things  which  nothing  far  short  of  omniscience 
could  have  detected  beforehand,  yet  often  the  disaster  can  be  directly 
traced  to  some  oversight,  carelessness,  or  want  of  judgment  or  of 
skill.^  No  operation  should  be  performed  except  in  urgent  cases, 
unless  the  patient's  history  and  general  condition  have  been  scrupu- 
lously inquired  into;-  even  in  cases  demanding  an  immediate  opera- 
tion, there  may  still  be  opportunity  for  incjuiry  as  to  previous  health 
and  habits,  and  to  examine  the  heart  and  lungs,  and  perhaps  the  se- 
cretions of  the  kidneys.  In  delayed  operations,  the  surgeon  would 
be  cul[)ably  negligent  who  di<l  not  inquire  into  constitutional  pe- 
culiarities, and  functional  and  organic  affections,  for  the  timely  dis- 
covery of  morbid  conditions  of  the  viscera  renders  possible  the  use  of 
approj)riate  remedies  before  the  operation. 

I.  DIAGNOSIS. 

The  first  step  in  the  management  of  the  case  is  the  determination 
of  the  nature  of  the  disease.  The  course  of  inquiry  must  be  most  ju- 
diciously and  systematically  made,  for  on  it  depends  the  course  of 
treatment  to  be  pursued.  An  error  may  be  attended  with  the  most 
serious  consequences  by  leading  to  the  omission  of  timely  and  im- 
portant remedies,  or  to  the  use  of  measures  which  are  detrimental.* 
It  may  thus  set  in  operation  a  series  of  pernicious  influences  for 
which  the  surgeon  will  be  held  rigidly  responsible.*  It  is  not  always 
possible  to  discover  the  exact  condition  of  a  diseased  or  injured  organ 
or  tissue,  and  it  is  a  fact  of  daily  experience  that  surgeons  of  the 
greatest  skill  will  differ  in  their  diagnosis  of  the  nature  of  a  given 
disease,^  but  failure  to  detect  the  more  obvious  and  essential  chau'jfes 
will  always  be  construed  as  culpable  negligence.  As  it  is  admitted 
that  errors  in  dia^rnosis  are  due  in  a  great  majority  of  cases  to  haste 
and  inattention,®  the  surgeon  should  seek,  by  thorou'^h  and  patient 
investi'^ation  of  every  case,  aided  by  the  most  approved  instnmients 
and  appliances,  to  protect  himself  from  such  a  charge.     The  ele- 

1  Sir. I.  Paset.      '  G.  VT.  <"allender.      3  Q.  H.  B.  McLeod.      *  J.  Ordronaux. 
6  Walflie  V.  Sayre.      ^  S.  D.  Gross;  T.  Holmes. 


6  OPERATIVE  SURGERY. 

ments  of  a  correct  diagnosis  are  found  in  (1)  the  history  of  the  pa- 
tient; (2)  the  progress  of  the  disease;  and  (3)  the  physical  examina- 
tion. An  investigation  wliicli  will  discover  and  place  in  their  jjroper 
relations  all  the  important  facts  bearing  on  the  nature  of  the  disease, 
must  develop  the  following  specific  inquiries,  under  the  several  heads 
above  given  :  — 

1.  The  history  of  the  patient  includes  the  following  series  of  in- 
quiries: sex,  in  its  tendencies  to  special  forms  of  disease  at  dif- 
ferent periods  of  life,  and  to  nervous  phenomena;  age,  as  it  affects 
the  development  of  bones  and  organs,  the  integrity  of  tissues,  and 
the  occurrence  of  organic  and  malignant  diseases;  heredity,  in  the 
perpetuation  of  diseases  and  peculiarities  of  ancestors;  previous  dis- 
eases, which  leave  their  sequelae,  as  syphilis,  scrofula;  occupation, 
which  develops  special  maladies,  as  necrosis  of  jaw  from  phos- 
phorus; habits,  with  which  certain  affections  are  likely  to  be  asso- 
ciated, as  venereal  diseases  with  prostitution,  nervous  derangements 
with  masturbation;  social  condition,  as  it  is  related  to  secret  or  con- 
jugal vices  of  the  sexes. 

2.  The  progress  of  the  disease  relates  to  the  following  special  sub- 
jects: date  of  the  attack  or  injury,  on  which  depends  the  progress 
of  the  malady;  alleged  changes,  which  may  be  the  clue  to  the  true 
cause;  symptoms  which,  taken  in  their  order  of  development,  give 
much  of  the  clinical  history,  and  afford  reliable  data  for  a  differen- 
tial diagnosis;  the  present  attitude,  form,  and  condition  of  the  part 
compared  with  the  past;  the  operations  which  may  have  been  per- 
formed and  their  results;  the  course  of  treatment  and  its  most  im- 
portant effects,  Avhich  may  be  the  very  touchstone  revealing  the 
nature  of  the  complaint.^ 

3.  The  physical  examination  must  be  made  with  all  necessary  aids 
and  aj)pliances,  visual,  manual,  and  instrumental.  First:  Color 
determines  the  circulation  in  a  part;  form  indicates  the  existence  or 
non-existence  of  enlargements  of  regions,  when  deciding  as  to  tu- 
mors, dislocations,  fractures;  transparency  reveals  the  presence  of 
serum,  as  in  hydrocele.  Second  :  Consistence  must  be  noted  in  in- 
flammatory swellings  and  tumors,  fluctuation  in  collections  of  fluids; 
crepitus  in  fractures;  crepitation  in  collections  of  air  or  gas  beneath 
the  skin.  Third:  The  exploring  needle  detects  the  consistence 
and  contents  of  swellings  and  tumors;  the  hypodermic  syringe  with- 
draws the  fluids  of  abscesses  and  cavities;  the  trocar  ^  removes  pieces 
of  muscle  for  examination;  the  microscope  determines  histological 
peculiarities;  the  ophthalmoscope  reveals  the  deep  structures  of  the 
eye,  the  laryngoscope  of  the  laryngeal  passages,  the  speculum  of  the 
ear,  the  vagina,  and  rectum,  and  the  urethroscope  of  the  urethra  and 
urinary  bladder. 

1  G.  H.  B.  McLeod.  2  Duchenne. 


THE  EXAMINATIOX.  7 

II.  PROGNOSIS. 
The  prognosis  is  an  estimate  of  the  results  which  will  follow  any 
operation.  It  must  depend  j)rimarily  upon  the  knowledge  obtained 
in  the  diagnosis,  and  secondarily  upon  that  larger  int^uiry  which 
seeks  to  discover  tendencies  and  conditions  affecting  the  ultimate 
is.>ue  of  diseases,  and  operative  procedures  undertaken  for  their 
cure.  The  chances  of  recovery  after  operations  are  so  largely  in- 
fiuenceil  by  the  jjrevious  state  of  the  patient's  constitution, ^  that 
special  inquiry  ^^hould  be  made  as  to  former  diseases  and  their  effects, 
and  the  existing  organic  and  functional  integrity  of  every  inijiortant 
organ.  Due  attention  should  also  be  given  to  mental  and  physical 
peculiarities,  and  to  those  surrounding  conditions  which  more  or  less 
directly  modify  the  ordinary  course  of  the  malady  under  observation. 
The  following  considerations  have  a  relative  importance,  and  should 
have  projx-r  weight  in  deciding  the  probable  issue  of  an  operation  : 

1 .  The  native  bears  operations  better  than  the  immigi-ant. 

2.  The  sex  which  has  the  greatest  endurance  is  the  female. ^ 

3.  The  age  is  not  in  itself  a  barrier  to  any  necessary  operation,^ 
but  witli  it  we  connect  the  most  regular  average  difference  in  capac- 
ity to  bear  operations;*  the  most  favorable  period  is  between  five 
and  fifteen;  the  next,  between  fifteen  and  thirty;  after  tlu'rty  the  risk 
to  life  is  more  than  twice  as  great  as  it  was  at  the  same  period  after 
birth.5  Young  and  healthy  children  ■*  are  in  danger  through  shock,  ag- 
gravated by  pain,  but  bear  very  well  the  loss  of  blood,  and  are  little 
liable  to  pyajuiia  after  wounds.  Old  ])ersons  *  are  likely  to  have  or- 
ganic diseases  and  degeneracies,  and  feeble  circulation,  inducing 
congestions,  due  to  sinking  of  the  blood  in  the  lungs,  liver,  intes- 
tines, and  other  dependent  parts;  are  liable  to  die  of  shock,  or  mere 
exliaustion,  and  do  not  bear  losses  of  blood,  lowering  of  tempera- 
ture, or  want  of  food;  they  convalesce  slowly,  or  after  partial  re- 
covery fade,  waste,  and  die;  but  the  thin,  dry,  tough,  clear- voiced, 
and  bright-eyed,  with  good  stomachs  and  strong  wills,  muscular  and 
active,  bear  very  well  all  but  the  largest  operations. 

4.  Constitutional  Diseases  *  influence  operations  as  follows  : 
Scrofula  oive-s  a  considerable  mortality,  but  its  ill  eflfects  are  seen 
chiefly  in  the  imperfect  healing  of  wounds,  the  swollen  cellular  tissue, 
the  thin  and  lowly  organized  cicatrix,  or  indolent  ulcers  and  sinuses; 
in  the  large  majority  of  chronic  cases  the  removal  of  a  scrofulous  part 
is  followcil  by  improved  health,  but  the  patient  remains  scrofulous, 
and,  if  old,  may  not  bear  confinement  well ;  sypliilis  is  liable  to  delay 
reparative  action,  and  the  operation  in  those  who  have  tertiary 
sores  may  be  followed  by  renewed  tertiary  symptoms;  rheumatism 
1  N.  Chevers.    2  \\\  g.  Savory.    3  s.  D.  Gross.    *  Siu  J.  Pagkt.    5  T.  Holmes. 


8  OPERATIVE   SURGERY. 

and  gout  predispose  to  structural  changes  of  arteries  and  kidneys, 
and  to  organic  diseases  of  the  lieart;  cancer  contra-indicates  opera- 
tions only  in  its  later  stages,  when  the  general  health  is  failing  ; 
anffiuiia  is  not  a  bad  condition  in  which  to  operate,  wounds  heal 
slowly  and  soundly,  but  if  erysipelas  or  like  casualties  supervene 
patients  are  less  likely  to  recover. 

5.  Habits  and  Temperament  ^  should  be  duly  considered ;  in- 
temperance increases  the  dangers  of  operations  in  proportion  as  it 
is  habitual;  slight  intemjDcrance  is  much  worse  than  occasional 
great  excesses;  avoid  operating  on  confirmed  drunkards,  unless  com- 
pelled by  the  necessity  of  the  case ;  operations  are  hazardous  on  all 
persons  who  require  stimulants  before  they  eat  or  work;  over-eating 
is  closely  allied  to  intemperance  in  increasing  the  dangers  of  oper- 
ations, esj^jccially  if  the  over-eating  is  of  meat  and  other  nitrogen- 
ous foods  ;  the  over-fat  are  a  bad  class,  when  their  fatness  is  not 
hereditary,  but  due  to  over-eating,  soaking,  indolence,  and  defective 
excretions,  their  pendulous  bellies  indicating  omental  fat,  and  defi- 
cient portal  circulation  ;  persons  in  whom  the  vital  processes  are 
weak,  but  without  morbid  action,  repair  wounds  feebly,  and  are  es- 
pecially liable  to  real  diseases  of  the  blood  and  tissues,  and  ojjer- 
ations  should  be  deferred,  if  practicable,  to  some  period  of  better 
health,  for  fear  of  local  failure,  rather  than  of  incurring  any  unusual 
risk  of  life  ;  allied  to  this  class  are  the  cold-blooded,  with  cold,  damp 
hands  and  feet,  dusky  appearance  of  vascular  parts,  feeble  circula- 
tion, small  pulse,  slow  digestion,  constipation ;  nervous  persons,  who 
are  exceedingly  mobile  and  excitable,  whether  in  their  sensitive  or 
motor  organs,  their  whole  cerebro-spinal  system  being  altogether 
too  alert  and  vivacious,  pass  through  the  consequences  of  oper- 
ations with  as  great  impunity  as  any  other  class;  malarial  affections 
do  not  contra-indicate  operations,  but  in  the  course  of  convalescence 
ague  fits,  resembling  those  which  precede  pyjemia,  may  occiu*. 

6.  Deranged  or  diseased  conditions  ^  of  organs  variously  affect 
the  results  of  operations;  of  the  digestive  organs,  gastric  dyspepsia 
is  followed  only  by  flatulence,  unless  vomiting  is  a  symptom  when 
anaesthetics  are  liable  to  excite  emesis,  with  dangerous  prostration ; 
great  caution  is  required  with  those  whose  biliary  secretions  are  ha- 
bitually unhealthy,  or  who  have  been  often  jaundiced,  or  who  have 
a  sallow,  dusky  complexion,  dr}'  skin,  dilated  small  blood-vessels 
of  the  face,  sallow  and  blooilshot  conjunctivae,  symptoms  which 
indicate  deranged  functions  and  al)doiiiinal  plethora;  enlargement  of 
the  liver,  whether  amyloid  or  fatty,  is  often  coincident  with  chronic 
diseases  of  the  bones  in  children,  and  eitliei*  tends  to  cause  death  by 
exhaustion,  or  secondary  hemorrhage;  of  the  organs  of  circulation, 

'  1  Sir  J.  P.voi-.T. 


THE  EXAMINATION.  9 

affections  of  the  heart  are  not  serious  hindrances  to  recovery  from 
operations;  shock  and  loss  of  blood  are  attended  with  more  than 
ordinary  risk  in  persons  whose  hearts  are  feeble  or  embarrassed  by 
valvular  obstruction,  but  a  rapid  or  irrejfular  pulse,  witliout  organic 
disease  of  the  heart,  and  with  respiration  not  exceeding  twenty  or 
twenty-five,  does  not  contra-indicate  an  operation;  degeneracies  of 
the  arteries  are  only  serious  when  general  in  the  extremities,  espe- 
cially the  lower,  rendering  primary  hemorrhage  diflicidt  of  control, 
and  secondary  hemorrhage  more  fre(pient  and  dangerous  after  ampu- 
tation, and  so  interfering  with  nutrition  that  destructive  supj)uration 
is  liable' to  occur,  with  slow  and  imperfect  healing  of  the  wound; 
diseased  veins  complicate  operations  only  when  varicose,  and  cut 
through,  as  in  amputations,  thus  exciting  inflammation;  of  the  dis- 
eases of  the  respiratory  organs,  chronic  bronchitis  and  emphysema, 
especially  in  old  people,  render  operations  extremely  hazardous, 
owing  to  imperfect  respiration,  cough,  and  loss  of  sleep;  phthisis, 
when  progressive,  adds  greatly  to  the  dangers  of  operations,  from 
the  consequent  fever,  loss  of  food,  and  pain,  but,  when  chronic, 
operations  are  advisable,  which  relieve  the  system  of  painful  and 
wasting  local  cliseases;  persons  suffering  from  long-standing  strumous 
affections,  with  the  appearance  only  of  tubercular  disease,  may  be 
greatly  benefited  by  the  removal  of  the  diseased  part  ;  menstruation 
and  prciinancy  are  conditions  rendering  operations  undesirable. 

7.  Various  other  affections  ^  modify  the  prognosis  as  follows:  se- 
vere operations  during  the  sta<xe  of  shock  after  injuries,  and  during 
the  period  of  acute  inflammation,  with  high  temperature,  are  danger- 
ous; spreading  erysipelas,  cellulitis,  and  gangrene  add  so  much  to  the 
dansers  of  severe  operations,  that  the 'chances  of  life  are  best  when 
only  the  ordinary  treatment  is  followed  ;  avoid  operations  in  acute 
pya;mia,  when  there  are  rigors  once  or  more  in  a  few  days,  and  pro- 
fuse sweatiuLis.  with  very  rapid  pulse  and  breathing,  and  with  delir- 
ium and  rapid  wasting,  or  with  dry  tongue  and  yellowness  of  skin, 
or  any  considerable  numl)er  of  these  symptoms;  but  an  operation  is 
justifiable  in  chronic  pyaemia  when  there  is  wasting  and  sweating, 
with  the  formation  of  abscesses  here  and  there,  and  the  injured  ])art 
is  manifestly  useless  and  a  source  of  irritation  or  of  exhaustion; 
croup  does  not  contra-indicate  tracheotomy,  nor  peritonitis  herniot- 
omy, which  are  operations  of  necessity,  and  are  not  materially  af- 
fected by  the  general  acuteness  of  the  existing  affections  ;  of  the 
diseases  of  the  kidney,  those  associated  with  the  constant  jwesenee 
of  albumen  in  the  urine  predispose  operated  patients  to  erysipelas 
and  pya^nia ;  pyelitis  renders  operations,  as  lithotomy,  lithotrity, 
and  even  catheterism  dangerous,  owing  to  the  liability  to  urinary 
1  Silt  J  Pagkt. 


10  OPERATIVE  SURGERY.     ■ 

fever  and  retention  of  the  materials  of  urine  in  the  blood;  of  the 
diseases  of  the  nervous  system,  delirium  tremens  is  an  indication  of 
a  complexity  of  risks,  and  forbids  all  large  operations,  except  from 
compulsion  ;  dysentery  and  acute  diarrhoea  are  unfa\orable,  espe- 
cially when  irritative  fever,  Avith  cellular  inflanmiation,  is  present; 
slight  and  transient  diarrhoea  is  serious  only  when  it  occurs  in  the 
old  or  young,  or  exhausted  ;  constipation  is  unimportant,  but,  when 
habitual,  copious  evacuations  may  prove  dangerously  prostrating  to 
the  feeble;  insanity  renders  patients  more  or  less  inditi'erent  to  pain 
and  local  injuries,  but  they  recover  from  chronic  ailments  with  diffi- 
culty. External  conditions  unfavorable  to  an  operation  are  the 
epidemic  prevalence  of  erysipelas,  or  low  forms  of  fever,  and  an 
atmosphere  contaminated  by  the  presence  of  any  contagious  diseases. 

III.  DECISION. 

The  decision  must  be  based  upon  the  preceding  investigation 
relating  to  the  diagnosis  and  prognosis.  The  question  of  an  opera- 
tion enters  as  a  new  and  most  important  eleuK^nt  in  the  case,  and 
always  demands  the  most  serious  consideration,  for  cutting  oper- 
ations must  be  regarded  as  injuries  inflicted  at  the  will  of  the  sur- 
geon, which  may  destroy  a  person  enjoying  comparatively  good 
health,  or  fatally  aggravate  other  but  not  serious  affections.  An 
operation  is  not  justifiable  when  the  patient  can  be  cured  by  any 
reasonable  medical  or  other  means;  and  if  the  disease  can  be  cured 
by  a  bloodless  operation,  as  well  as  by  one  with  cutting,  choose  the 
bloodless  method,  for  the  danger  is  comparatively  slight  when  the 
operation  does  not  involve  the  injury  of  tissues.^  Any  operation  is 
of  undoubted  propriety,  which  is  immediately  necessary  to  save  life, 
as  tracheotomy  in  laryngeal  obstructions  ;  excision  of  poisoned 
wounds;  or  when  it  is  less  severe  than  other  measures,  as  excision 
of  small  growths,  instead  of  employing  caustics;  or  when  it  is  the 
only  measure  possible,  as  amputation  of  crushed  limbs;  or  the  last 
resort,  all  other  suitable  remedies  having  failed,  as  herniotomy  in 
strangulated  hernia.  But  frequently  the  question  of  operation  is 
involved  in  doubt  and  uncertainty,  often  requiring  for  its  proper 
solution  a  nice  appreciation  of  pathological  conditions,  operative 
procedures,  and  reparative  processes.  It  is  a  well  established  fact 
that  surgeons  may  honestly  differ  in  their  views  as  to  whether  an 
operation  would  produce  a  cure,  or  be  of  some  benefit,  although 
not  a  radical  cure;  or  whether  the  benefit  would  justify  the  oper- 
ation; or,  finally,  whetber  the  operation  could  be  performed  at  all 
without  destruction  of  life.^  In  whatever  form  the  question  of  an 
operation  is  j)resented,  all  of  the  evidence  for  and  against  it  should 
1  Sir  J.  Pagut.  2  Walsh  v.  Savre. 


THE   PREPARATIOX.  11 

be  personally  considered  by  the  surgeon  with  judicial  impartiality. 
In  many  instances  it  can  only  be  determined  by  the  judicious  dis- 
crimination of  existing  conditions,  which  are  often  complex.  He 
should  never  be  over-persuaded  by  patient  or  friends,  nor  unduly 
influenced  by  counsel,  to  ojjerate  against  convictions  deliberately 
formed ;  neither  the  consent,  nor  even  request,  of  the  jiatient  can 
justify  such  an  operation. 

The  Consent  1  of  the  })atient,  or  of  those  responsible  for  him,  to  the 
operation  should,  if  possible,  always  be  obtained.  If  he  is  not  ca- 
j)able,  as  v.'hen  intoxicated  or  comatose,  or  if  he  is  a  child,  and  par- 
ents or  guardian  are  inaccessible,  ojjerate  only  from  clear  necessity. 
In  order  that  he  or  they  may  form  a  correct  judgment,  communicate 
the  decision,  and  the  reasons  that  have  led  to  the  conclusion; 
make  every  necessary  explanation  as  to  the  nature  of  the  injury  or 
malady,  its  probable  course  and  termination,  and  the  advantages, 
disadvantages,  and  liabilities  of  the  proposed  operation;  thus  you 
will  discharge  every  obligation,  and  remit  to  the  patient,  or  friends,  or 
guardian,  the  responsibilities  of  a  final  judgment  as  to  the  course 
of  procedure.  As  far  as  practicable,  the  deliberations  of  the  patient 
and  his  advisers  should  be  influenced  by  no  other  considerations  than 
those  presented  by  the  surgeon.  Should  the  decision  be  favorable 
to  an  operation,  the  patient  again  returns  to  the  surgeon's  care, 
and  a  new  series  of  obligations  is  incuiTed.  The  preparation  for  the 
operation,  its  manual  performance,  and  the  after  treatment,  present 
questions  which  will  tax  his  knowledge,  skill,  and  care. 


CHAPTER  III. 

THE  PEEPARATIOX. 

No  ingenuity  of  conception  or  brilliancy  of  execution  of  the  opera- 
tor can  excuse  the  neglect  to  secure,  by  jirevious  preparation,  every 
possible  advantage  which  can  in  any  way,  however  trivial,  minister 
to  success;  even  a  successful  issue  cannot  justify  the  surgeon  in  sub- 
jecting his  patient  to  an  avoidable  risk.- 

I.   TATIKXT. 

The  first  care  must  be  given  to  the  patient.  It  is  important  that 
every  organ,  and  the  entire  system,  be  so  prepared  for  the  injury 
about  to  be  inflicted,  that  the  issue  will  be  favorable;  for  the  timely 
discovery  of  morbifl  conditions  of  the  viscera,  and  the  use  of  appro- 
priate remedies  before  the  operation,  might,  in  a  large  j)roportion  of 
1  F.  C.  Skey.  2  av.  s.  Savorv. 


12  OPERATIVE  SURGERY. 

cases,  prevent  disastrous  results.^  The  effects  of  habits  of  excess- 
ive bodily  indulgence  in  food  and  stimulants  may  be  amended  in  a 
comparatively  short  time  ;  previous  rest,  important  to  the  recovery 
of  the  part  about  to  be  operated  upon,  may  be  secured ;  ^  slight  de- 
rangements, which  are  readily  amenable  to  treatment,  may  at  once 
be  corrected,  such  as  indigestion,  constipation,  diarrhiea;  grave  affec- 
tions of  the  kidneys,  liver,  heart,  lungs,  and  nervous  centres  may  be 
so  improved,  or  the  system  so  protected,  that  the  operation  will  not 
be  serious.  Even  cold-blooded  persons,  with  feeble  circulation,  when 
suitably  prepared  by  tonics,  as  iron,  improve  their  condition,  and  bear 
operations  well,  being  singularly  little  liable  to  erysipelas,  pyaemia, 
and  other  disorders  of  the  blood.^  The  patient  should  be  placed 
under  the  most  favorable  hygienic  conditions  ;  pui'e  air,  suitable 
exercise,  wholesome  food,  and  undisturbed  sleep  are  imj)ortant  feat- 
ures in  the  final  preparation  ;  the  morale  must,  as  far  as  possible, 
be  sustained  by  such  assurances  as  will  secure  mental  quietude  and 
hopefulness  as  to  the  result  of  the  operation;*  do  not  exaggerate 
its  nature,  but  speak  encouragingly  of  it,  and  of  its  prospective 
success.^  Finally,  as  a  severe  shock  to  the  nervous  system,  pro- 
duced by  an  exhaustive  surgical  operation  and  prolonged  anaesthesia, 
may  for  a  time  so  paralyze  the  stomach  that  digestion  ceases,  or  is 
greatly  impaired,  and  the  food  that  it  contains  at  the  moment  may 
undergo  such  putrefactive  changes  as  will  render  it  an  irritant,  the 
food  taken  within  six  hours  of  the  operation  should  be  quickly 
assimilable,  and  in  limited  quantities  ;  milk  is,  in  general,  the  best 
food  for  this  purpose,  especially  with  children,  to  which  may  be 
added  a  small  amount  of  whiskey;  a  warm,  well-seasoned,  and  well- 
cooked  cup  of  broth,  or  a  fragrant  cup  of  hot  coffee  and  milk,  may 
be  preferred  by  the  adult.  ^ 

II.    TIME. 

The  time  appointed  must  be  so  fixed  as  to  avoid  the  error  of 
omission,  delay;  and  of  commission,  haste,  by  a  careful  consideration 
of  the  nature  of  the  disease,  the  condition  of  the  patient,  and  the 
surrounding  circumstances.  It  must  be  immediate  when  life  is 
threatened,  and  the  operation  offers  the  only  chance  of  recovery, 
and  should  be  delayed  when  any  of  the  conditions  enumerated 
would  render  the  operation  dangerous  to  life  or  abortive  in  its 
results.  But  not  unfrequently  the  disease,  the  patient,  and  the  cir- 
cumstances combine  to  enable  the  surgeon  to  appoint  the  month,  the 
day,  and  the  hour.  The  employment  of  anaesthetics  has  so  dimin- 
ished the  fear  of  operations  that  the  surgeon  may  exercise  his  dis- 

1  N.  Chevers.  2  \\.  S.  Savory.  3  Sir  J.  Paget.  4  Ch.  S(^diIlot 

5  A.  H.  Stevens.        6  p.  H.  Hamilton. 


TIIK   PREPARATION.  13 

cretion  as  to  the  propriety  of  informing  the  patient  of  the  day  and 
hour  tielected.^ 

1.  The  month-  slioulil  be  seleeted  with  regard  to  those  meteorolog- 
ical comlitions  which  are  known  to  affect  the  results  of  operations, 
namely,  temperature,  humidity,  and  pressure  of  the  atmosphere. 
The  mortality  from  shock  is  greatest  in  dry  and  least  in  damp 
weather;  the  mortality  from  fever  and  pyaemia  is  greatest  in  damp 
and  least  in  dry  weather;  the  month  of  least  mortality  from  all 
causes  after  operations  is  October  in  this  latitude,  which  has  a  high 
dew-point,  medium  relative  humidity  and  range  of  temperature,  and 
low  barometer;  then  January  and  April  ;  the  month  of  greatest  mor- 
tality, from  all  causes  after  operations,  is  December,  then  May  and 
November;  the  least  mortality  from  shock  occurs  in  October;  then 
in  September,  August,  January,  March,  and  April  ;  the  least  mor- 
tality from  fever  and  pyaemia  occurs  in  February;  then  in  April,  No- 
vember. Januaiy,  and  July. 

2.  The  day  should  be  selected  with  reference  to  the  temperature 
and  humidity  of  the  air.  It  is  always  better  to  defer  an  operation 
which  falls  u])on  a  rainy  or  inclement  day  to  one  of  sunshine.^  The 
barometer  is  the  best  guide,  as  it  forecasts  the  weather  several  hours. 
The  following  facts'^  are  important  :  The  least  mortality  occurs  with 
an  ascending  barometer;  next  when  it  is  stationary;  the  mortality 
with  a  descending  barometer  is  nearly  three  times  greater  than  with 
an  ascending  barometer. 

3.  The  hour  best  adapted  for  operations,  on  account  of  both  light 
and  dryness  of  the  air,  will  fall  between  11  o'clock  a.  m.  and  3 
o'clock  p.  M. 

III.    PLACE. 

In  the  selection  of  the  place  reference  must  be  had  to  the  comfort 
and  safety  of  the  patient. 

1.  The  office  of  the  surgeon  is  frequently  the  most  convenient  place, 
but  a  risk  to  the  patient  may  thereby  be  incurred,  which  it  is  better  to 
avoid,  namely:  the  liability  of  rendering  a  simple  operation  danger- 
ous by  the  subsequent  imprudent  conduct  of  the  patient,  as  exposure 
to  the  elements,  excitement,  fatigue,  or  excesses  of  appetite* 

2.  The  room  in  the  private  dwelling  should  be  chosen  for  its  ac- 
cessibility, its  size,  and  its  exposure  to  light  at  the  hour  of  the  opera- 
tion; the  best  light  in  a  clear  day  for  delicate  operations  is  reflected 
from  the  northern  sky.  The  air^  of  the  room  in  which  an  operation- 
wound  is  inflicted  should  he  as  free  as  it  can  be  made  from  all  forms 
of  putrefactive  organisms ;  it  should  not  immediately  communicate 

1  C.  Sedillot.  2  A.  IIewsox.  8  fi.  W.  Dudley.  ■»  Sir  J.  Paget. 

6  S.  D.  Gross. 


14  OPERATIVE  SURGERY. 

with  water-closets,  and  other  sources  of  defilement,  nor  be  occupied  as 
a  living  or  audience  room.  The  best  results  after  large  operations 
have  been  obtained  when  the  operating  room  has  been  first  purified 
by  suljdiur,  and  both  operator  and  assistants  have  bathed  and  had 
their  clothes  and  all  the  materials  used  about  the  wound  thoroughly 
disinfected.^ 

IV.  INSTRUMENTS. 

In  selecting  instruments  care  must  be  taken  that  they  are  of  ap- 
proved utility  and  in  good  condition.  The  surgeon  cannot  employ 
rude  articles,  as  a  butcher's  knife  or  a  carpenter's  saw,  in  amputa- 
tion, unless  he  is  placed  under  circumstances  which  prevent  his  ob- 
taining suitable  instruments.'^  And  he  is  required  to  employ  the 
more  recently  devised  instruments  which  have  been  reconnnended  by 
the  best  authorities  as  preferable  to  those  formerly  in  use,  provided 
they  are  reasonably  accessible  to  him.  They  must  be  in  good  order, 
as  dull  knives,  broken  forceps,  imperfect  saws,  seriously  complicate 
operations.  They  must,  finally,  be  kept  in  a  state  of  scrupulous 
cleanliness,  as  blood  and  pus  may  conve}'  contagion  to  the  person 
next  operated,  and  rust  and  filth  may  fatally  poison  a  wound.  The 
minor  apj)aratus  also,  as  the  plaster,  the  ligatures,  the  sutures,  must 
be  carefully  selected,  for  many  an  operation  has  been  spoiled  by  bad 
silk,  or  needles,  or  something  that  was  thought  too  trivial  for  care.^ 
Every  practitioner  should  know  how  to  select  and  take  proper  care 
of  instruments.  In  order  to  do  this  intelligently  he  must  understand 
something  of  the  mechanism  of  instruments. 

1.  The  materials  4  of  which  the  blades  of  general  operating  instruments  are 
marie  are  steel,  silver,  platinum,  gold,  and  aluminum.  German  steel  is  used  for 
forceps  and  blunt  instruments,  owing  to  its  tenacity;  English  cast-steel  for  edge- 
tools,  as  it  receives  a  high  temper,  a  fine  polish,  and  retains  its  edge.  Silver, 
when  pure,  is  very  flexible,  and  is  useful  for  catheters  which  require  frequent 
change  of  curve  ;  when  mixed  with  other  metals,  as  the  silver  coin,  it  makes 
firm  catheters,  caustic  holders,  and  canulated  work ;  seamless  silver  instruments 
are  least  liable  to  corrode.  Platinum  resists  the  action  of  acids  and  ordinary 
heat,  and  is  useful  for  caustic  holders,  actual  cauteries,  and  the  electrodes  of  the 
galvano-cautcry.  Gold,  owing  to  its  ductilit}',  is  adapted  for  fine  tubes,  as  eye- 
syringes  and  points  of  needles.  Aluminum  is,  by  extreme  lightness,  suited  for 
probes,  styles,  and  pessaries.  German  silver  and  brass  plated  instruments  are 
used  extensive!}',  owing  to  their  cheapness.  The  handles  may  be  made  of  ebony, 
ivory,  shell,  or  hard  rubber.  Ebony  is  more  generally  used  for  larger  instru- 
ments, owing  to  its  durability  and  neatness.  Ivory  is  more  expensive,  but 
makes  a  beautiful  and  durable  handle.  Shell  is  more  used  for  light  instruments, 
as  those  of  the  common  pocket-case.  Hard  rubber  makes  an  excellent  handle, 
combining  neatness,  lightness,  and  durability,  and  is  coming  more  and  more  into 
use.  Next  to  materials,  the  making  of  the  instrument  determines  its  quality  ; 
and  hence  the  importance  of  selecting  those  manufactured  by  entirely  reliable 
workmen.     If  the  steel  is  overheated  in  the  forge  the  knife  will  be  brittle  orrot- 

1  C.  Schroeder.    2  Young  v.  Fullerton.    3  Sir  j.  Paget.    ^  Tiemaxn  &  Co. 


THE  PREPARATION.  15 

ten;  in  shaping  it  with  the  tile  tlie  form  may  be  destroyed;  in  "  hardcninf;^ "and 
tempering,  the  steel  may  be  spoiled;  in  grinding  and  glazing  the  instru- 
ment may  be  rendered  worthless.  In  every  stage  of  its  manufacture,  therefore, 
the  value  of  an  instrument  depends  upon  the  personal  skill  of  the  workman. 
The  last  act  of  the  maker  is  to  polish  and  sharpen  the  instrument,  and  thus  ada|)t 
it  for  use. 

2.  The  tests  1  of  the  quality  of  instruments  are  as  follows  :  Draw  a  cutting 
instrument  from  heel  to  point  slowly  across  the  border  of  the  nail,  and  it 
will  catch  or  stop  at  every  "  nick  ;  "  draw  it  across  the  fat  of  the  nail,  and  if 
at  any  point  the  etige  is  seen  to  be  wiry  or  smooth,  it  is  soft,  and  must  be  re- 
applied to  ihe  hone;  but  if  it  becomes  serrated,  like  a  fine  saw,  the  edge  is  brit- 
tle, and  cannot  be  remedied  by  the  hone.  For  pointed  instruments,  stretch  upon 
a  test  drum  (a  contrivance  for  the  purpose  for  sale  by  instrument  makers)  a  verv 
thin  i)iece  of  kid  or  gold-beater's  skin,  and  push  the  point  through.  If  it  enter 
smoothly  and  easily  the  point  is  good  ;  but  if  a  slight  crackling  noise  is  heard  it 
is  defective.  If  a  lancet  is  tested,  see-saw  the  edge  in  the  opening,  and  if  it 
glides  over  without  cutting,  or  cuts  roughlv,  the  edge  is  imperfect. 

3.  The  preservation'  of  instnunents  in  good  condition  requires  careful  at- 
tention to  the  following  details  :  Select  a  place  always  free  from  moisture  and 
dirt  for  their  safe  keeping.  Polished  instruments  should  be  suspended  or 
placed  in  velvet-lined  cases.  After  being  used,  every  instrument  should  be 
thoroughly  cleaned  with  warm  water,  and  perfectly  dried  with  chamois,  or  the 
tire,  before  it  is  returned  to  the  ease.  Silver  instruments  tarnish  when  they  are 
exposed  to  the  air,  or  are  brought  in  contact  with  hard  or  soft  rubber,  caustics, 
or  acids.  To  preserve  the  edge  and  polish  of  instruments,  the  surgeon  requires 
two  or  three  small  hones,  some  fine  emery  paper,  two  or  three  screw-drivers, 
small  files,  rouge  crocus,  or  other  polishing  powder,  chamois,  and  gold-beater's 
or  kid  skin.  Cutting  instruments  should  have  their  blades  kept  in  perfect  order 
by  the  judicious  use  of  the  hone.  Occasionally  the  blade  must  be  ground  by  a 
competent  workman.  IJlunt  instruments,  which  are  designed  to  enter  natural 
or  other  passages,  should  be  frequently  polished  with  fine  emery  paper,  and  then 
with  rouge  and  chamois  skin,  in  order  to  remove  every  particle  of  rust,  and  to 
maintain  smooth  unblemished  surfaces.  Saws  are  sharpened  with  three-cor- 
nered files,  applied  in  the  direction  of  the  original  cut  of  the  teeth. 

The  case  of  instruments  wliieli  the  surgeon  must  provide  depends 
upon  the  variety  of  operations  whieh  he  undertakes;  if  limited  to 
trifiin;;  operations,  he  requires  only  the  poeket  case;  if  he  per- 
form minor  operations,  he  requires  the  minor  operating  case;  if  he 
assumes  every  grade  of  operation,  he  must  add  the  general  operat- 
ing case.  In  selecting  any  case  tlie  surgeon  should  e.xercise  liis  own 
judgment  as  to  the  number  and  kind  of  instruments,  rather  tlian  ac- 
cept the  list  of  the  maker,  or  of  any  other  surgeon.  The  best  as- 
sorted case  contains  many  instruments  which  the  general  practitioner 
never  has  occasion  to  use.^ 

V.  CONVALESCENCE. 
The  hygienic  conditions  which  surround  a  patient,  the  fubject  of 
an  operation,  materially  affect  the  results.'    Foul  air,  filthy  dressings, 
1  TiEMA^x  &  Co.  2  J.  E.  Ericlisen. 


16  OPERATIVE  SC^RGERY. 

indii-estible  food  will  thwart  the  best  })lanned  and  executed  op- 
eration.^ It  is,  therefore,  the  duty  of  the  surgeon  to  secure  to  the 
patient  all  the  advantages  which  healthful  conditions  afford. ^  These 
are  largely  found  in  the  room  and  its  various  appointments. 

1.  The  room  in  the  private  dwelling  best  adapted  for  convales- 
cence is  on  the  second  floor  from  the  ground;  the  exjjosure  should  be  to 
the  south,  with  ample  window  space,  and  with  opposite,  or  partially 
opposing,  windows  for  thorough  ventilation.  The  size  of  the  room 
is  of  slio-ht  importance,  except  as  to  convenience,  compared  with  the 
provisions  for  the  outflow  of  foul  air  and  the  inflow  of  fresh  air. 
Large  cubic  space  does  not  secure  purity  of  the  air,  and  hence  is  of 
minor  importance  if  the  necessary  amount  of  fresh  air  is  supplied 
and  properly  distributed  without  unpleasant  currents.^  It  would, 
however,  always  be  wise  to  provide  at  least  two  hundred  feet  super- 
ficial area  and  three  thousand  cubic  feet  of  air  to  the  patient  and 
his  attendant,  each,  during  the  first  weeks,  to  guard  against  de- 
fects in  ventilation.  As  in  private  residences  there  are  no  other 
motors  for  changing  the  air  than  differences  of  temperature  and 
movement  of  the  air,  which  can  be  excited  by  heat  or  wind-fans, 
these  agents  must  be  employed  to  give  motion  to  the  air.*  The  com- 
mon open  fire-place,  well  heated,  furnishes  the  best  heat  supply  for 
movements  of  the  air,  while  the  inlet  and  outlet  of  air  is  maintained 
by  raising  and  dropping  the  sashes  of  the  windows.  The  walls 
should  be  freshly  lime- washed,  floors  cleaned  with  carbolic  solution; 
no  sink  for  slops,  nor  wash-bowls  drained  into  common  house-drains, 
nor  water-closet  should  be  in  or  communicate  with  the  room  ;  ^  the 
furniture  should  be  as  free  as  possible  from  absorbent  materials;  bed 
and  window  hangings,  carpets,  and  upholstery  are  objectionable,  and 
if  old  are  dangerous.  Floors,  furniture,  and  wood- work  should  be 
cleansed,  Avithout  water,  by  rubbing  with  an  absorbent  material.^  Do 
not  place  the  bed  near  the  wall,  in  a  corner,  nor  in  air  draughts. 

2.  The  ward  of  the  hospital  to  which  the  patient  is  to  be  con- 
veyed should  be  free  from  suppurating  wounds,  erysipelas,  and  low 
forms  of  fever ;  the  bed  should  be  exposed  to  the  sunlight,  with 
any  necessary  screen  to  the  face ;  it  should  have  at  least  one  hun- 
dred feet  of  superficial  area,  and  four  thousand  cubic  feet  of  air; 
the  position  of  the  bed  should  be  three  or  four  feet  from  the  wall, 
with  complete  ventilation  around  it;  if  the  tick  is  filled  with  straw 
it  must  l)e  fresh  ;  if  a  hair  mattress  is  used,  it,  with  the  bed  linen, 
should  be  clean,  and  previously  well  aired  and  sunned. 

3.  The  nurse  should  be  skilled  in  the  care  of  persons  suffering 
from  operations,  for  frequently  success  depends  upon   the   skill  in 

1  S.  D.  Gross.       2  Sir  J.  Paget.       3  J.  S.  Billings.        ■*  M.  Pettenkoffer. 
5  Sir  J.  Paget;  S.  D.  Gross.         6  A.  Smith. 


THE  ILKMORRIIAGE.  17 

the  nianascment  of  the  details  of  nursing  after  special  operations. 
Cleanliness  of  the  woiiml,  the  patient,  the  clothing,  the  room,  are 
of  the  first  iini)ortance  ;  the  diet  and  the  remedies  are  to  be  care- 
fully attenileil  to,  and  the  progress  of  the  case,  as  indicated  by  the 
wound,  the  pulse,  and  the  temperature,  is  to  be  noted  at  sulficiently 
freciuent  intervals  to  make  the  record  of  the  case  complete  in  the 
absence  of  the  surgeon. 

IV.  ARRANGEMENTS. 

The  immediate  preparations  for  the  operation  must  be  com- 
plete in  all  their  details,  and,  as  far  as  practicable,  should  be  \wv- 
sonally  supervised  by  the  surgeon.  Provide  a  firm  table  of  suitable 
hei<Tht,  in  all  operations  of  any  magnitude,  and  spread  over  it  two 
or  three  folds  of  blankets.  Beds  and  sofas  are  no  substitutes  for  the 
table.  Wlienever  practicable,  as  in  hospitals,  a  well  constructed 
operating  table  should  always  be  employed.  Provide  water,  hot 
and  cold,  in  abundance,  with  wasli-bowls,  slop-pails,  and  jars;  also 
clean  towels,  and  clean  old  linen;  select  one  competent  per.«on  to 
administer  the  anassthetic;  one  trained  surgical  assistant,  who  is  fa- 
miliar with  the  methods  of  operating,  and  is  prepared  to  anticipate, 
or  to  promptly  meet  every  want  or  emergency;  two  ordinary  assist- 
ants to  supply  fresh  water,  cleanse  sponges,  and  answer  calls;  arrange 
the  instruments  which  are  to  be  used  on  a  convenient  stand,  and  in 
the  order  they  will  be  required,  and  cover  them  until  the  patient  is 
placed  on  the  table;  direct  the  patient  to  wear  clothing  loose  about 
the  neck  and  chest,  and  admitting  of  full  exposure  of  the  parts  to  be 
operated  upon;  administer  the  ana?sthetic  after  the  patient  is  placed 
on  the  table,  to  avoid  the  inconveniences  of  carrying  an  insensible 
person,  unless  through  fear,  or  other  disturbing  causes,  seclusion  is 
necessary. 


CHAPTER   lY. 

THE  HAEMORRHAGE. 

One  of  the  most  important  duties  of  the  surgeon  is  to  deal  eco- 
nomically with  the  blood  of  the  patient  committed  to  his  chartre.^ 
E.xcessive  bleeding,  due  to  defective  measures  for  its  jirevention,  is 
culpable  negligence.'^  It  is  important,  therefore,  to  make  suitable 
])reparatioii  for  the  prevention  of  ha?morrha<re.  These  measures 
must  be  adapted  both  to  control  the  circulation  in  the  limb,  or  part, 
iluring  the  operation,  and  to  i)ermanently  close  the  divided  vessels 
after  the  operation. 

1  F.  EsMARCH.  *  F.  C.  Skev. 

2 


18 


OPERATIVE  SURGERY. 


I.    ELASTIC   COMPRESSIOX. 
The  most  perfect  method  of  preventing  loss  of  blood  dnrino-  the 
operation  is  by  elastic  compression  so  applied  as  to  remove  the  blood 
from  the  part  and  jjrevent  it  from  reentering  the  vessels. 

1.  The  elastic  bandage  i  (Fig.  1)  is  the  most  serviceable  and 
convenient  appliance  yet  devised  to  meet  all  of  these  important  indi- 
cations. In  operations  on  the  lower  limb  select  a  bandage  made 
of  woven  India-rubber,  and  of  sufficient 
length  to  extend  from  the  foot  to  the  hip, 
where  it  is  fastened  by  a  clasp  (Fig.  2), 
or  by  the  rubber  tubing  sometimes  used. 
While  the  patient  is  being  brought  under 
Fig.  1.  the  anaesthetic,  apply  the  bandage,   with 

uniform  tightness,  from  the  extremities  of  the  toes  or  fingers,  accord- 
ing to  the  limb  about  to  be 
operated  upon,  to  a  point 
aljove  the  place  of  opera- 
ion  ;  where  the  bandage 
ends    apply    the    India-iub- 


FiG.  2. 

ber  tubing,  well  drawn  out,  four  or  five  times  round  the  thigh,  and 
connect  one  end  with  the  other  by  means  of  a  hook  and  brass 
chain,  or  apply  the  clasp  (Fig.  2);  now  remove  the  bandage  first 
applied,  commencing  with  the  last  turn,  and  descending  to  the  toes 
or  fingers,  leaving  the  tubing  in  position  ;  the  India-rubber  tubing 
so  thoroughly  compresses  all  the  soft  parts,  including  the  arteries, 
that  not  a  drop  of  blood  can  enter  the  parts  below ;  even  in  the 
most  muscular  and  stoutest  individuals  we  are  able  thoroughly  to 
control  the  supply  of  blood  by  this  simple  process  ;  the  limb  below 
the  tubing  resembles  completely  that  of  a  corpse,  and  we  may  opei-- 
ate  as  on  the  dead  subject  ;  this  method  may  be  adopted  in  almost 
all  operations  on  the  extremities  with  more  or  less  complete  success; 
in  extirpation  of  tumors,  tying  of  arteries,  scraj)ing  off  of  scrofulous 
ulcers  and  carious  bones,  and  in  resections  of  smaller  bones  and  joints, 
the  compressing  tubin<r  need  not  be  relaxe<l  until  the  dressing  of  the 
>WGund  is  completely  finished  ;  as  in  the  extremities,  so  the  supply 
of  blood  to  the  male  genital  organs  can  be  entirely  cut  off  by  the  In- 

1   F.  ESMARCH. 


THE  II^EMOnnilAGE. 


19 


(lia-rubbcr  tubing ;  to  remove  a  testicle  or  amputate  the  penis,  apply 
a  thin  India-rubber  tubing  from  behind  round  the  root  of  the  scro- 
tum and  penis,  cross  the  ends  in  front  on  the  mons  veneris,  and  tie 
them  on  the  loins ;  the  tubing  may  perhnps  be  found  useful  in 
operations  on  the  trunk,  neck,  and  head,  by  shutting  off  the  blood 
of  all  or  some  of  the  extrennties,  from  the  general  circulation,  by 
strappinii,  and  thus  forming  reserve  stores  from  which  we  could 
admit  the  blood  successively  again  into  the  general  circulation,  if  the 
patient  were  in  danger  of  bleeding  to  death  ;  the  dangers  which 
may  arise  from  this  method  are  not  determined,  but  we  must  not  ig- 
nore the  possibility  that  the  firm  strapping  of  a  limb  for  any  consid- 
erable time  may  be  followed  by  serious  derangements  of  the  circula- 
tion and  innervation,  such  as  thrombosis,  inflammation,  paralysis, 
etc.;  when  operatin.;  upon  parts  infiltrated  with  ichorous  matters, 
it  would  be  a  wise  precaution  not  to  apply  the  bandage,  but  to  raise 
the  limb,  and  empty  the  vessels  as  completely  as  pos.-ible  before  ap- 
plying the  tubing.^ 

2.  Elastic  rings^  of  proper  size,  rolled  upwards  from  the  extremity 
of  the  limb  etlectually  suppress  all  circulation.  Tlie  advantages 
are  complete  control  of  the  circulation,  and  simplicity  and  facility 
of  application.  A  set  of  rings  contains  nine  sizes,  the  smallest 
being  of  solid  rubber  cord,  and  one  half  an  inch  in  diameter,  the 
largest  being  of  rubber  tubing,  and  four  and  a  half  inches  in  diameter. 
Select  a  ring  suited  to  the  limb  to  be  operated  upon,  and  roll  it 
slowly  from  the  extremity  upwards,  sufficiently  above  the  point  of 
operation  ;  the  rings  for  the  arm  and  forearm  should  fit  the  wrist 
firmly,  and  those  for  the  thigh  and  leg  the  ankle  ;  in  applying  the 
rings,  one  side  may  be  raised  to  pass  ~ 
painful  or  diseased  parts,  or  the  ring 
may  be  stretched  and  placed  above 
the  seat  of  injury  or  disease,  thereby 
avoiding  the  forcing  of  septic  fluids 
into  the  circulation. 


II.  ARTERIAL  COMPRESSIOX. 
The  control  of  the  circulation  may 
be  effectefl  by  compression  of  the 
artery  which  supplies  the  part.  As 
this  method,  however  cai'cfully  ap- 
plied, permits  of  the  loss  of  the  blood 
contained  in  the  limb,  the  amount 
should  be  diminished,  as  far  as  pos-  Fig  3. 

sible,  by  elevating  the  limb,  and  rubbing  towards  the  heart. 
>  F.  EsMAKCH.  '  A.  E.  Spoiin. 


20 


OPERATIVE  SURGERY. 


1.  The  Fingers  afford  ready  and  available  means  of  arterial 
compression  when  the  artery  is  accessible,  iind  lies  upon  a  bone. 
(Fig.  3.)  If  the  thumb  is  used,  it  must  be  laid  flat  upon  the  vessel; 
in  either  case  the  pressure  must  not  be  relaxed;  if  the  vessel  slips 
from  the  grasp  it  should  be  instantly  compressed  again  upon  the 
bone  by  the  fingers  or  thumb,  but  not  by  grasping  the  limb ;  the 
fingers  are  best  employed  in  compression  of  the  brachial,  the  radial, 
and  the  ulnar  arteries;    the  thumb  in    compressing  the   abdominal 


Fig.  4. 

against  the  vertebras,  the  external  iliac  against  the  brim  of  the  pelvis, 
the  femoral  against  the  pubes,  or  in  the  upper  part  of  the  thigh. 

2.  The  key,  the  ring  being  so  padded  as  to  make  a  hard  mass, 
is  used  to  compress  deep-seated  arteries,  as  the  subclavian. 

3.  The  tourniquet  has  several  modifications  (Fig.  4,   a,  b,  c), 

but  the  most  important  difference  is 
in  the  effect  upon  the  venous  cir- 
culation ;  they  may  compress  the 
limb  only  at  opposite  points  (a) ;  or 
the  entire  limb,  the  pad  being  placed 
over  the  artery  (6,  c).  The  most 
useful  instrument  is  that  in  com- 
mon use  {by.  In  its  application  it 
is  usual  to  put  several  turns  of  a 
roller  aroimd  the  limb  at  the  point 

j  where  it  is  applied,  terminating  with 
placing  the  cylinder  of  the  roller 
over  the  artery  as  a  compress;  the 
tourniquet  should  now  be  applied, 
but  the  screw  should  not  be  placed 
over  the  cylinder,  lest  the  ball  roll  from  the  artery  when  the  screw  is 
1  J.  L.  Petit. 


Fig. 


THE   U HEMORRHAGE. 


21 


Fk;. 


worked.  The  screw  beint;  placed  at  one  side  of  the  limb  (Fig.  .5), 
tlie  strap  should  be  buckled  tightly,  and  the  screw  gradually  turned 
to  the  necessary  tightness;  if  there  is  a  liability  of  the  slipping  of 
the  compress,  put  the  cylinder  of  the  roller  between  the  pad  and  the 
strap,  and  apply  it  to  the  artery.  The  tournitpiet  may  be  specially 
adapted  to  compress  the  abdominal  aorta, ^  or  it  may  be  devised  to 
compress  ciilicr  the  femoral,  the  aorta,  or  other  large  arteries. 

4.  The  ligature  is  sometimes  usefully  applied  to  the  main  artery 
of  the  limb  or  part  to  be  operated,  as  to  the  common  carotid  artery 
in  operations  on  the  face  and  mouth. ^ 

III.   LIGATION. 

The  application  of  the  ligature  to  cut  vessels  is  the  favorite  method 
of  controlling  bleeding  during  and  after 
the   operation.     The   material   employed 
may  be   irritating  or  non-irritating  ;  the 
former  induces  suppuration,  and  must 
be  removed  from  the  wound  when  the 
vessel  is  closed ;  the  latter  causes   no 
suppuration,  and  may  be  inclosed  in 

the  wound.  In  applying  the  ligature  the  coats  of  the  artery  should, 
as  far  as  possible, 
be  isolated  from 
surrounding  tis- 
sues with  the 
tenaculum  (Fig. 
6),  or  the  ten- 
aculum    forcejis 

(Fig.  7),  or  the  dog-tooth  forceps.  Draw  the  artery  well  out, 
and  press  the  knot  down  with  the  index  fingers 
(Fig.  9);  to  ap|)ly  the  ligature  accurately  the 
forceps  should  have  a  slide  (Fig.  8)  which,  drawn 
up  while  the  ligature  is  cast  around  the  points  of 
the  forceps,  may  then  be  forced  down,  and  will 
carry  the  ligature  directly  upon  the  artery  as  the 
first  knot  is  being  tightened.  If  necessary,  seize 
several  bleeding  vessels  before  the  ligatures  are  applied  to  restrain 
immediate  ha?morrhage,  as  when  assistants  are  not  at  hand,  and 
employ  any  form  of  catch  or  claw  forceps  that  may  be  at  hand. 
(Fig.  10.) 

1 .  The  silk  ligature,  though  irritating,  is  still  generally  prcferreil. 
It  should  have  three  threads  and  be  so  firm  as  to  resist  the  utmost 
strain  of  the  fingers.      In   its  application   make  the  surgeon's  knot 

»  J.  E.  Erichsen;  J.  Lister.       "  V.  Mott.       3  i).  Prince.      <  n.  J.  Bigklow. 


Fig.  8.4 


22 


OPERATIVE  SURGERY. 


(Fig.  11;  or  the  sailor's  knot  (Fig.  12).     To  tic  the  latter  knot,  hold 

the  ligature  between 
the  thumb  and  finger 
of  the  right  hand  ; 
throw  the  end  round 
the  forceps,  and  seize 
the  body  of  the  liga- 
ture between  the  mid- 
dle and  ring  finger  of 
the  left  hand,  in  a 
Fig.  10.  prone  position,  the  end 

being  grasped  between  the  thumb  and  index  finger;  draw  the  thread 


Fig.  11.  Fig.  12. 

in  the  right  hand  over  the  end  of  the  left  index  finger  and  the  ex- 
tremity of  the  ligature,  and  pass  it  between  the  ends  of  the  index 
and  middle  fingers;  now  taking  the  end  of  the  ligature  from  the 
grasp  of  the  left  index  finger  and  thumb  with  the  right  index  finger 
and  thumb,  the  knot  is  completed  by  drawing  out  the  portion  passed 
between  the  left  index  and  middle  finger;  in  tying  the  second  knot 
the  action  of  the  hands  must  be  reversed.  Cut  one  end  near  the 
knot  and  draw  the  other  out  of  the  most  depending 
part  of  the  wound.  In  some  cases  the  bleeding 
vessels  can  not  be  isolated,  and  it  becomes  neces- 
sary to  enclose  a  small  area  with  a  ligature  (Fig. 
13)  passed  around  it  with  a  needle. 

2.  The  hemp  ligature  differs  from  the  silk  only 
in  its  want  of  pliabilitv,  being  much  more  inflex- 
ible. 

3.  The  catgut,  carbolized,  is  a  non-irritating  liga- 
ture, and  seems  to  fulfill  all  the  conditions  of  a  perfect  ha?mostatic, 
combining  the  security  and  universal  applicability  of  the  ligature 
with  the  absence  of  a  foreign  body  in  the  wound. ^  After  the  knot  is 
tied,  both  ends  of  the  ligature  should  be  cut  off  and  the  wound  per- 
manently closed. 

IV.   TORSION. 

The  twisting  of  an  artery  upon  its  axis  is  designed  to  cause  lacera- 
tion of  the  internal  coats  of  an  artery;  they  then  roll  into  the  calibre 

1  J.  Lister. 


Fig.  13. 


THE  ILEMOmUlA  GE. 


23 


of  the  vessel  and  form  a  mesh,  within  which  a  blood  clot  forms  and 
becomes  organized;  the  external  twisted  coat  remains  as  a  protection 
and  support.  Torsion  is  a  reliable  method,*  especially  when  applied 
to  small  arteries,  bnt  is  not  generally  approved  for  large  arteries. 
I.  Free  torsion  is  applicable  to  small  arteries,  and  consists  in  seiz- 
ing the  extremity  of  the  vessel  with  firmly  uniteil  forceps, 
drawing  it  out  from  its  connections,  and  rotating  it  several 
times. 

2.  Limited  torsion  is  apijlied  to  large  arteries,  as  fol- 
lows: — 

Seize   tlie    extremit}-   of    the   artery  with    strong    catch    forceps, 

liaving  blunt 
serration  s  ; 
draw  it  well 
out      of      its 

sheath;  grasp  it  firmly  with  a  second  forceps  about  one  inch  from  the  end;  now 
rotate    the    first  forceps   three   or  four   times,  or  until  all   resistance   ceases. 

(Fig- 14.) 

y.  ACUPRESSURE.-! 

Compression  of  the  artery  in  the  wound  by  means  of  a  needle  is 
reliable  in  the  arrest  of  bleeding, ^  prevents  secondary  hajmorrhajre 
even  when  the  condition  of  the  blood  or  artery  predisposes  to  such 
accidents,  is  adapted  to  cases  in  which  the  artery  cannot  be  seized 
or  is  friable,  admits  of  the  ready  closure  at  the  same  time  of  the 
veins,  and  protects  the  interior  of  the  wound  from  forei'jrn  matters 
on  Avithdrawal  of  the  needles  in  twenty  four  to  forty-ei<dit  hours.* 
The  instruments  required  are  bayonet-pointed  pins,  v;irvinix  in  len<rth 
from  three  to  five  inches,  with  glass  heads  to  facilitate  their  intro- 
duction, needles  threaded  with  iron  wire,  and  loops  of  slender  an- 
nealed iron  wire,  five  or  six  inches  in  length.  On  the  cut  su7-face 
of  a  llap  the  ordinnry  sewing  needle  answers  perfectlv  well.  There 
are  several  methods  of  employing  the  pins  to  accomplish  compres- 
sion, but  they  may  be  reduced  to  three. 

1.  Direct  compression  (Fig.  15)  is  made  by  the  pin  thrust 
through  the  flap,  passed  over  the 
artery,  and  brought  out  of  the  integu- 
ment of  the  opposite  side,  in  such  man- 
ner as  to  firmly  compress  the  mouth  of 
the  artery  against  the  muscle  upon 
which   it    jifs. 

2.  Compression  -with  Tvire   is  ef- 
fected by  passing  the  point  of  the  pin 
under  the  vessel,  then  casting  over  it 
and  in  front  of  the  artery  a  loop  of  wire  which  is  tightly  fastened  to 
the  shaft  of  the  pin;  the  pin  is  then  passed  through  the  opposite  flap. 

1  T.  Bryant.         -  J.  Y.  Simpson.        s  T.  Holmes.        ••  J.  C  Hutchison. 


Fto.  15. 


24 


OPERATIVE  SURGERY. 


3.  Compression  by  torsion  (Fig.  16)  is  made  by  transfixing  the 


wuund  by  a  pin  an  inch  or  more,  A, 
on  the  side  of  the  artery,  then  carry- 
ing it  half  way  around  the  face  of  the 
stump  or  wound  to  B,  and  thrusting  it 
into  the  tissues  beyond. 

The  time  for  the  removal  of  the  pins 
or  noodles  should  not  exceed  forty-eight 
hours  fur  the  larger  and  twenty-four 
hours  for  the  smaller  arteries,  and  even  a 
much  less  period  has  been  found  to  suf- 
tice.i 


Fig.  16. 


VI.     C0NSTRICTI0N.2 
This  method  of  arresting  hfemorrhage  requires  the  rupture  of  the  in- 
ternal and  middle  coats  of  the  artery  by  means  of  a  constrictor; 
the  ruptured  coats  contract,  retract,  and  curl  up  (Fig.  1  7) ;  the 
I  L)(J     external  coat  is  drawn  over  and  firmly  compressed,  causing 
p>   <^    invagination  of  the  internal  coats;   an  internal  coagulum  now 
'  nn  1   forms,  while  the  integrity  of  the  external  coat  and  the  con- 
tinuity of  the  vessel  are  preserved  (Fig.  18).    The  advantages 
of  this  method   are  that  it  is  efficient,  safe,  and  easily  ap- 
plied; no  internal  coagulum  is  necessary,  as  the  invagination 
of  the  internal  and  middle  coats  is  sufficient  to  arrest  hiemor- 
rhage  ;  no  foreign  body  is  left  in  the  wound;  tliei'e  is  no  risk 
of  secondary  liEomorrhage,  pyaemia,  or  phlebitis  ;  it  is  appli- 
FiG.  17.   cable  to  all  sizes  and  conditions  of  arteries  where  the  external 
coat  is   perfect;  it  has  a  uniform  effect,  and  requires  but  little   skill 
or  practice  in  its  application,  and  the  management  of  details. 
I       I  I   The    instrument    consists    of    a   flattened    metal   tube,    six 
Vj(JJ  inches  (more  or  less)  in  length,  open  at  both  ends,  with  a 
sliding  steel  tongue  running  its  entire  length,  and  having  a 
Qf^\  vice  arrangement  at  the  upper  extremity,  by  which  it  can  be 
III      made  to  protrude  from  or  retract  within  the  tube  or  sheath  ; 
^m       the  lower  end  of  the   tongue    is    hook-shaped,  so  as   to   be 
T        adapted  to  the  artery  to  be  constricted  ;  it  is  so  shnpod  that 
having  grasped  an  artery,  it  can  be  made  to  contract  upon 
it   bv    means  of 


/r 


Fig.  18 
the    si 


the  vice  at  the 
upper  end,  which 
forces  it  witliin 
leath     (Fig.    19); 


Fig.  I'J 


the  hook  of  th'e  tongue  is  so  shaped  and  grooved  as  to  form  only 
1  G.  A.  Peters.  2  s.  F.  Si'IER. 


THE  HEMORRHAGE. 


25 


a  compressing  surface,  by  which  means  the  artery,  when  acted  upon 
bv  tlie  force  of  the  vice,  is  compelled  to  assume  the  form  of  the  curve 
of  the  tonjj;ue,  and  the  artery  is  constricted  in  such  a  way  that  its 
internal  ami  middle  coats  give  way,  but  the  ex- 
ternal coat  is  j)reserved  intact. 

It  is  applied  as  follows:  Seize  the  artery  with  a  teiiac-     I  ■' 
iiltiin,  or   forceps  ;    pass  the  tongue  of   the  constrictor 
arounil  the  vessel  and  draw  it  tightly  upon  the  artery 
by  means  of  the  vice  arrangement  at  the  end  (Fig.  20); 
when  the  screw  turns  with  considerable  resistaiice,  or  Fig.  20. 

the  internal  coats   are  seen  to  be    invaginaled  by  no- 
ticing tlieir  movements  in  the  end  of  the  artery,  detach  the  tongue,  and  the 
operation  is  completed. 

VII.    AERTIVERSION.' 

This  method  is  desij:ned  to  reinforce  the  cut  extremity  of  the 
artery  by  duplicature  of  its  walls,  and  thus  secure  such  an  amount  of 
muscular  structure  around  the  cut  end  as  will  effectually  close  its 
calibre  against  the  impulse  of  the  heart's  action. 

The  advantage  of  the  method  is,  that  it  leaves  nothing  but  living  tissues  in 
the  wound.  There  is  a  tendency,  by  the  alternating  distention  and  contraction 
of  the  vessel,  to  force  the  reflections  back. 

The  operation  is  readily  made  with  an  instrument  (Fig.  21)  hav- 


7^ 


Fig.  21. 


ing  a  tenaculum  point;  this  is  easily  introduced  within  the  artery, 
and  holding  the  margin  with  the  forceps,  traction  on  the  hook  in- 
verts the  coats,  as  the  cuff  of  a  sleeve  is  rolled  backward. 


VIII.    CAUTEItIZ.\TIOX. 

The  cautery,  once  the  only  method  of  arresting  blecdin<r  after 
operations,  is  now  reipiired  only  when  deep  seated  ])arts  are  involved, 
or  tissues  to  which  tlu!  liirature  cannot  safely  be  applied. 

1.  The  actual  cautery  consists  of  an  iron  or  steel  knob,  at  the 
extremity  of  a  long         —  ,^^        • 

handle.    The  shape  , , ..^ 

of     the     extremity 

may    be    round,   or  «^'  ^S 

pear-shaped,  or  flat  ^'<'-  ~. 

like  a  button  ;  each  form  is  .adapted  to  special  conditions  requiring 

its  use.      It  may  be  heated  in  the  flame  of  a  spirit  lamp;  when  em- 

1  G.  C.  E.  Weisek. 


26 


OPERATIVE  SURGERY. 


ployed  to  arrest  hfemorrliage  its  temperature  should  be  at  a  dull  red 
heat. 

2.  The  thermo-cautery  ^  (Fig.  23)  is  a  very  ingenious  instru- 


Fig.  23.2 


ment  by  which  a  high  degree  of  heat  of  the  cautery  may  almost  in- 
stantly be  obtained,  and  may  be  maintained  for  any  length  of  time 
■without  the  slightest  inconvenience.  It  is  peculiarly  useful  in  ope- 
rative procedures  in  the  mouth,  vagina,  and  rectum.  By  adapting 
a  blade  to  it,  dissections  may  be  made,  and  with  the  wire  ecraseur, 
tumors  may  be  removed  in  a  bloodless  manner. 

The  hard  rubber  receiver,  to  which  the  hook  is  attached,  is  filled  with  wool. 
By  removing  Ihe  screw  button,  onlj'  a  sufficient  cuantity  of  benzine  or  gasoline 
is  poured  in  to  saturate  the  wool  ;  with  the  hook  the  receiver  may  be  attached 
to  a  button  iiole.  By  compressing  the  rubber  bulb,  the  air  passes  into  the  tliin 
rubber  bag  covered  with  netting,  for  the  purpose  of  causing  a  continued  stream 
of  air.  The  air  being  saturated  by  its  passage  through  the  liard  rubber  receiver, 
is  forced  through  the  instrument  into  the  platina  point  No.  1,  having  passed 
through  the  platina  coil  upon  the  end  of  the  tube.  The  instrument  maj'  be  ig- 
nited by  a  match,  and  the  white  or  dull  red  heat  required  upon  the  platina  points 
is  regulated  by  drawing  down  the  platina  cone  upon  the  cylinder,  which,  being 
attached  to  a  spiral  spring,  yields  to  the  pressure  of  the  thumb.  The  stop- 
cock regulates  the  volume  of  air  to  be  passed.  Various  platina  points,  knife- 
shaped,  flat,  and  needle  pointed,  are  easily  attached. 


CHAPTER  V. 

THE  ANESTHESIA. 

Ax^STiiESiA  is  the-  first  recognized  stage  in  all  operations,  and 
the  surgeon  is  held  strictly  responsible  for  the  selection  and  adminis- 
tration of  the  proper  acrent.^  He  may  also  be  charged  with  im- 
proper conduct  by  female  patients  to  whom  he  has  administered  an 

1  M.  Paquelin.  2  Tikmann  &  Co.  3  Bogle  v.  Winslow. 


THE  Ay^ESrilKSIA.  27 

anEesthetic.^  Protection  from  tlie  charge  of  neglij^enee  is  found  in 
strict  conformity  with  the  established  rules  of  administration, ^  and 
from  the  charge  of  immoral  conduct  by  the  presence  of  a  third 
party. 

I.     GENERAL  ANAESTHESIA. 

Anaesthesia  8  may  be  partial,  full,  profound,  or  fatal,  with  no  dis- 
tinct boundary  lines  between  the  degrees.  The  two  intermediate 
degrees  constitute  ana-sthesia  proper,  the  first  of  which  is  desired 
in  surgery  ;  to  produce  and  maintain  this  stage  of  narcosis  with 
safety  is  a  delicate  api)lication  of  means  to  an  end;  the  e.xact  rela- 
tion of  the  thing  to  be  done,  and  the  power  apj)Iied  to  do  it,  in- 
volves the  whole  question  of  selecting  an  anajsthetic,  and  forbids 
the  arbitrary  or  exclusive  use  of  either  of  the  well-known  employed 
agents.  The  agents  which  have  been  well  tried  up  to  the  present 
time  are  nitrous  oxide,  ether,  and  chloroform ;  with  jjroper  discrim- 
ination in  applying  each  of  these  to  its  appropriate  uses  only,  and 
proper  skill  in  their  employment,  all  of  the  legitimate  purposes  of 
anajsthcsia  can  be  accomplished  with  reasonable  safety. 

1.  Nitrous  oxide  ^  is  noticeable  for  the  certainty  of  its  effects,  the 
prompt  recovery  of  patients,  and  its  safety.  It  is  best  adapted  to 
the  momentary  operations  of  minor  surgery,  because,  to  produce 
complete  ana'sthesia,  it  must  be  inhaled  nearly  or  quite  pure,  which 
entirely  deprives  the  blood  in  the  lungs  of  the  supply  of  air.^  An 
average  of  about  seven  gallons  of  gas  is  required  for  complete  anaes- 
thesia, and  from  one  to  two  minutes  to  produce  the  desired  effect. 
The  ana;sthesia  is  of  about  one  to  one  and  a  half  minutes  in  dura- 
tion, and  passes  off  almost  entirely  in  three  or  four  minutes. 

2.  Sulphuric  Ether  ^  is  a  safe  and  reliable  anjesthetic;  when  it  is 
slow  in  its  operation,  or  has  a  long  and  troublesome  stage  of  ex- 
citement, or  fails  to  produce  sudicient  ana?sthesia  unless  an  excessive 
amount  is  administered,  there  is  mismanagement  in  its  use.  Its  effi- 
ciency depends  upon  the  degree  of  concentration  in  its  adminis- 
tration; hence  the  necessity  of  using  such  an  apj)liance  as  will  sup- 
ply the  ether  vapor  to  the  patient  in  a  concentrated  form.  The 
simple  cone  of  towels  will  answer,  but  an  apparatus,  suitably  pre- 
pared, is  preferable. 

Select  a  stiff  towel.*  properly  folded  ;  it  should  be  a  new  one,  of  prettj'  good 
size,  taken  just  as  it  comes  from  tlie  laundry;  unfold  no  further  than  to  display 
it  in  tlie  diineusious  of  alxiut  ten  inches  by  five;  fold  down  two  of  the  corners 
in  such  a  way  that  thoy  shall  lap  over  each  othcv  a  little,  and  secure  them  by 
Stout  pins;  a  cone  will  thus  be  made  which  fits  the  face  aduiirably;  the  thick 
layers  of  towellinjTj  will  hold  suthcient  ether,  and  its  texture  will  prevent  a  too  free 
dilution  of  the  anivsthetic  by  the  atmospheric  air,  provided  the  apex  and  seam 

1  r.  Reale.  •  Bogle  r.  Wiuslow.  8  k.  r.  Squibb. 

*  Conniiitlee  of  boston  Society  for  Medical  Iuii)rovcmeut. 


28 


OPERATIVE  SURGERY. 


Fig.  24. 


of  the  cone  are  carefully  and  tightly  closed,  either  by  pins  or  the  fingers;  as  the 
cone  becomes  collapsed  by  saturation,  it  should  from  time  to  time  be  opened,  and 
kept  in  shape  by  distending  it  with  the  hand;  unless  these  details  are  attended 
to,  and  especially  the  closure  of  the  apex  of  the  cone,  the  induction  of  anesthe- 
sia will  be  uncertain  and  protracted;  in  anything  so  porous  as  a  towel  or  sponge, 
the  difficultly  is  to  exclude  enough  air.  A  simple,  effective,  and  .nexpensive 
apparatus!  (Fig.  24)  nia\'  be  obtained,  which  consists  of  a  wire  frame-work, 
sufHcientl3-  large  to  cover  the  lower  part  of  the  face;  the  wires  are  parallel,  and 
about  an  eighth  of  an  inch  apart;  between  the  wires,  from  side  to  side,  a  strip  of 
bandage  two  and  one-half  inches  wide  is  passed ; 
the  instrument  is  about  four  inches  long,  and 
three  inches  at  its  greatest  width,  and  yet  it 
consumes  more  than  three  yards  of  bandage 
when  passed  between  all  the  wires;  each  sec- 
tion of  the  bandage  is  separate  from  the  ad- 
joining one,  thus  permitting  the  air  to  pass 
freely  to  both  sides  of  it;  over  this  frame  is 
drawn  a  piece  of  stout  sheet  India-rubber,  or 
patent  leather,  which  has  been  stitched  to- 
gether at  the  edges,  so  as  to  make  a  covering  for  the  frame,  projecting  over  one 
end  two  inches,  to  form  the  mask,  and  at  the  other  one  inch.  The  ether  is 
poured  on  the  bandage,  which  forms  a  close,  well-made  artificial  sponge  ;  the 
instrument  is  especialh'  serviceable  when  a  prolonged  use  of  ether  is  required. 

The  cone  or  apparatus  having  been  properly  prepared,  pro- 
ceed as  follows  :2  First  give  the  patient,  fasting,  about  fifteen  min- 
utes before  the  time  set  for  operation,  a  fluidounce  or  a  fluidounce 
and  a  half  of  brandy  or  whiskey,  if  an  adult  male,  or  two  fluidounces 
of  Avine  if  a  female  ;  this  produces  slight  intoxication  in  about  ten 
minutes,  shortens  the  stage  of  excitement  in  many  cases,  and  ren- 
ders retching  less  likely  to  occur  ;  the  patient  is  then  placed  quietly 
on  the  table,  and  is  advised  in  a  low,  quiet  tone,  to  be  composed 
and  perfectly  still;  about  ten  minutes  before  the  time  for  operation, 
the  patient  is  required  to  smell  the  ether  strongly  at  each  inspiration, 
for  the  purpose  of  getting  used  to  it ;  this  establishes  tolerance  or 
partial  anaesthesia  of  the  mucous  membrane  of  the  air-passages,  and 
thus  avoids  some  of  the  coughing  and  strangling ;  the  quantity  of 
ether  for  the  first  charge  should  vary  with  the  estimated  sensibility 
of  the  patient.  For  an  adult  man,  one  and  a  half  to  two  fluidounces, 
and  for  females  and  sensitive  males  one  to  one  and  a  half  fluidounces 
is  suflicient,  if  the  ether  be  good;  for  children,  a  half  to  one  fluid- 
ounce.  The  most  convenient  place  for  the  manipulator  is  at  the  head 
of  the  table,  whence  he  can  best  apply  a  hand  to  either  side  of  the 
patient's  face,  and  thus  support  the  cone  in  position  without  much 
jn'essure ;  the  thumljs  naturally  fall  into  the  fossa;  on  each  side  of  the 
nose,  while  the  fingers  support  the  part  under  the  chin,  care  being 
taken  not  to  press  upon  the  larynx;  if  the  patient  has  a  beard,  it 
1  C.  N.  Allis.  ^  E.  R.  Squibh. 


THE  AN.ESTnESIA.  29 

should  be  wetted  to  render  it  less  pervious  to  air*  if,  after  a  few  in- 
spirations of  the  concentrated  vapor,  respiration  is  suspended,  re- 
move the  apparatus,  but  as  soon  as  respiration  is  reestablished,  re- 
place it  over  tlie  nose  and  mouth;  if  restless  excitement  occurs,  avoid 
obstruction  to  ihe  mouth  and  nose,  but  under  no  circumstances  allow 
the  apparatus  to  drop  off  during  the  excited  movements;  if  retching 
occur,  continue  the  ether,  but  if  actual  vomiting  is  imminent,  remove 
it  momentarily.  The  patient  soon  passes  into  the  third  or  required 
stage  of  narcosis,  often  with  a  shudder,  or  slight  general  convulsion. 
Watch  the  pulse,  respiration,  and  color  of  the  surface  throughout, 
and  test  the  e\e  or  the  roots  of  the  nails  from  time  to  time  to  ascer- 
tain the  condition  as  to  insensibility;  as  soon  as  this  is  fairly  estab- 
lished, begin  the  operation.  In  a  large  proportion  of  cases  not  more 
than  four  of  the  eight  minutes  will  have  been  consumed.  When 
the  operation  is  fairly  under  way,  and  no  sensibility  shown,  remove 
the  ether  to  avoid  the  fourth,  or  snoring  stage  of  narcosis,  and  re- 
place it  when  signs  of  sensibility  are  seen. 

3.  Chloroform  1  is  the  most  rapid,  certain,  and  effective  ana\<thetic; 
the  facility  and  simplicity  of  its  administration,  the  small  quantity 
required,  the  certainty  of  good  quality,  its  non-inflammability,  its 
cheapness,  its  agreeable  odor,  combine  to  render  its  use  popular; 
but,  unfortunately,  sudden  and  overwhelming  paralysis  of  the  heart, 
commonly  called  cardiac  syncope,  which  is  beyond  human  skill  and 
knowledge  to  foresee  or  prevent,  occasionally  causes  death  by  it. 
Hence,  great  care  is  necessary  in  the  use  of  chloroform,  when  or- 
ganic disease  of  the  heart  is  present;  but,  though  patients  with 
very  weak,  fatty  hearts  are  in  somewhat  greater  danger  from  chloro- 
form than  other  persons,  yet,  when  cautiously  given,  they  may  take 
it  safely,  and  in  valvular  disease  the  risk  of  chloroform  would  be 
less  than  that  of  the  pain  and  alarm  attending  any  considerable  oper- 
ation without  it. 2  The  administration  should  be  by  an  experienced 
assistant.  Preparatory  to  taking  chloroform'  the  patient  should  be 
directed  to  omit  the  last  meal  which  would  naturally  precede  it,  and 
to  loose  any  tight  band  around  the  neck  and  waist;  arrange  a  common 
towel  so  as  to  form  a  square  cloth  of  six  folds;  pour  upon  it  enough 
chloroform  to  moisten  a  surface  in  the  middle  about  as  large  as  the 
palm  of  the  hand,  the  precise  quantity  used  being  a  matter  of  no  con- 
setpience;  hold  the  cloth  as  near  the  face  as  can  be  c<mifortably  borne, 
more  chloroform  being  added  occasionally  as  may  be  necessary ;  con- 
tinue the  administration  until  the  eyelids  cease  to  move  when  the 
conjunctiva  is  touclu-d  with  the  finger;  meanwhile  watch  the  breath- 
ing careftdly,  and  if  at  any  time  it  become  obstructed  or  strongly 
stertorous,  remove  the  cloth  and  draw  the  tip  of  the  tongue  firmly 
forwards  till  the  tendency  to  obstruction  has  disappeared. 

1  E.  R.  Sqliub.  2  Sir  J.  Paget.  8  j.  Lister. 


30 


OPERATIVE  SURGERY. 


4.  Rapid  respiration^  will  induce  a  sufficient  degree  of  ansesthesia 
to  admit  of  slight  oj)erations  without  pain,  as  the  passage  of  a  probe 
into  wounds,  or  manipulation  of  injured  limbs  and  inflamed  parts. 
The  patient  must  be  required  to  breathe  rapidly  for  about  three  min- 
utes, when  there  will  be  tingling  of  the  surface,  especially  of  the 
fingers,  a  feeling  as  if  the  surface  were  swelling,  dizziness  or  confu- 
sion in  the  head,  without  obliteration  of  consciousness.^ 


II.  LOCAL  ANESTHESIA. 
In  trivial  operations  involving  slight  incisions,  as  opening  abscesses, 
local  anEesthesia  is  preferred.     It  consists  in  benumbing  the  surface 
with  cold,  or  an  anaesthetic.^ 

1.  Ice  is  applied  as  follows:  pulverize  finely  and  mix  with  half  its 
bulk  of  salt;  apply  the  mass  in  a  gauze  net  or  an  India-rubber  bag; 
continue  its  application  only  until  the  surface  is  pale,  bloodless,  and 
insensible;  if  continued  too  long,  a  frost  bite  or  chilblain  will  follow. 

2.  Ether  in  the  form  of  spray  is  a  very  efficient  and  simple  method 
of  relieving  a  part  of  sensibility.  For  this  purpose  a  spray-produc- 
ing apparatus  is  required. 

The  most  efficient  ansesthetic  refrigerator*  has  a  continuous  jet  and  con- 
sists of  a  bottle  for  ether  and  a  bel- 
lows with  a  reservoir  ;  put  the  ether  in 
the  bottle,  nearly  tilling  it,  then  insert 
the  tube  with  the  cork  firmly,  and  fit 
the  nozzle  to  give  the  jet  desired. 
Grasp  the  bulb  on  the  extremity  of  the 
rubber  tubing  and  use  it  as  a  hand- 
bellows,  the  other  bulb  acting  as  a  res- 
ervoir; the  small  wires,  st^-lets,  are 
used  to  graduate  the  spray,  which  is 
made  finer  or  heavier  by  the  use  of 
different  sizes;  remove  the  nozzle  and 
insert  the  stylet  in  the  small  tube.  A 
very  efficient  refrigerator,  with  con- 
tinuous jet,  may  have  the  bottle  as  the 
reservoir  (Fig.  25). 

3.  Liquefied  carbolic  acid,®  retained  in  contact  with  the  skin  for 
two  or  three  minutes,  causes  a  white  spot,  which  is  soon  surrounded 
by  a  congested  circle;  serum  is  next  effused,  which  raises  the  skin 
in  a  wheal  ;  the  smarting  or  pain  now  subsides  and  ana?sthesia  be- 
gins in  the  white  part,  while  the  congested  part  becomes  hypera^s- 
thetic  ;  the  ana?sthesia  is  at  its  height  in  fifteen  or  twenty  minutes, 
and  involves  the  skin  down  to  the  cellular  tissue;  the  affected  tissues 


Fig.  2.5.6 


1  W.  G.  A.  Bonwill. 
6  G.  Tiemann  &  Co. 


-  A.  Hewson. 
6  J.  H.  Bill, 


3  J.  Arnott.      4  B.  W.  Richardson. 


THE   OPERATION.  31 

may  be  punctured,  cut,  or  burned  without  sensation;  soaking  the 
parts  witli  dilute  acetic  acid  increases  the  effect  of  the  carbolic  acid; 
wounds  made  in  tissues  thus  treated  heal  rapidly- 


CHAPTER  VI. 

THE    OPERATION. 

The  manual  part  of  the  operation  may  be  one  step  in  the  treat- 
ment of  a  disease,  or  it  may  comprise  the  entire  responsibility  of  the 
surgeon,  as  in  cases  where  he  is  required  only  to  operate.  The  re- 
auit  may  depend  upon  other  conditions  than  the  operation,  or  upon 
the  operation  alone  ;  in  either  case  he  is  required  to  bring  to  the  dis- 
charge of  his  duties  the  skill  requisite  to  properly  accomplish  the 
object.^  The  plan  of  the  operation  should,  when  practicable,  be  care- 
fully matured,  ami,  if  it  is  difficult  or  complex,  be  practiced  on  the 
subject  frequently  before  tin-  time  fixed. ^  Regard  must  be  had  for 
established  metliods  in  similar  conditions,  for  the  surgeon  will  be 
responsible  for  any  unfavoraljle  results  following  a  departure  from 
the  ordinary  and  approved  rules. 

I.   INSTRUMENTS. 
All  operations  reqiure  the  knife,  the  forceps,  and  the  director  ;  for 
special  operations,  special  intruments  are  necessarv. 

1.  The  knife  may  be  in  the  form  of  a  scalpel  or  bistoury;  the  scalpel 
is  of  several  sizes,  and  the  blade  varies  in  breadth,  the  broad  blade 
being  adapted  to  large  and  deep  incisions,  the  narrow  to  more  deli- 
cate dissections;  the  bistoury  varies  much  in  the  shape  of  the  blade, 
being  curved  or  straight,  sharp  or  probe  pointed,  broad  or  narrow, 
and  with  full  or  partial  cutting  edge. 

2.  The  forceps  should  have  serrated  claws  and  a  spring  so  firm  that 
tlie  extremities  hold  firmly  under  strong  pressure;  the  common  dis- 
secting forceps  loose  their  hold  when  the  limbs  are  pressed  together, 
and  thus  render  dissection  tedious  and  embarrassing. 

3.  The  director,  being  used  to  raise  thin  tissues,  as  fascia,  for  inci- 
sion, should  have  a  deep  groove  terminating  in  a  slight  cul-de-sac  to 
prevent  the  escape  of  the  point  of  the  knife. 

II.  DISSECTION. 

The  process  of  exposin<r  deep-seated  parts  is  the  dissection.     The 

practiced  operator  »  familiar  with  the  use  of  his  knife,  and  confident 

in  himself,    divides  l)oldly  and  freely,  his  progress  is  clearer  at  every 

incision,  his  work  is   systematic,  he  proceeds   slowly  and    steadily, 

'  J.  Ordronaux.  2  V.  Mwtt.  8  f.  c.  Skey. 


32 


OPERATIVE  SURGERY. 


every  cut  tells,  and  every  movement  has  a  meaning  and  an  object;  but 
timidity  marks  the  ignorant  man  at  every  step,  and  uncertainty 
and  indecision  characterize  his  movements;  he  passes  from  one  part 
of  the  wound  to  another  without  any  rational  object  or  intention, 
dissecting  a  little  here  and  dividing  a  little  there,  but  completing 
nothino'  ;  finding  his  own  resources  fail,  he  lends  an  ear  to  the  sug- 
gestion of  one  and  another,  and  adopting  imperfectly  the  advice  of 
each,  protracts  the  ojieration  three  or  four  times  the  necessary 
period. 

1.  The  hand'  best  adapted  to  make  the  dissection  is  the  right;  it 
will  be  of  advantage  to  dissect  occasionally  with  the  left,  but  there 
are  few  who  will  attain  the  same  command  over  it  as  over  the  right 
hand;  besides  the  left  always  has  important  duties  to  perform  and 
may  be  said  to  be  the  servant  of  the  right. 

2.  The  position'  in  which  the  knife  is  held  varies  with  the  kind  of 
incision  to  be  made;  the  most  general  position  is  nearly  identical  with 
that  of  a  pencil  or  pen  when  held  in  the  act  of  writing  (Fig.  26),  the 

/  thumb  being  applied  on  one  surface 
of  the  handle,  the  index  finger  on  the 
back,  and  the  middle  placed  par- 
tially behind  to  regulate  somewhat 
the  force  employed  by  the  index,  and 
the  little  finger  resting  on  the  body; 
this  position  is  adapted  to  cutaneous 
incisions  requiring  caution  in  the  de- 
gree of  pressure,  as  in  an  operation 
Fig.  26.  for  hernia,  aneurism.    For  great  del- 

icacy and  convenience  of  manipulation  the  knife  is  held  like  the 
violin  bow  (Fig.  27),  the  thumb  antagonizing  all  the  fingers.      This 

position  enables  the  operator  to  make 
a  transverse  incision.  By  turning 
the  knife,  held  in  either  of  these 
positions,  upon  its  axis,  other  posi- 
tions are  assumed,  the  first  adapted 
to  opening  abscesses,  and  the  sec- 
ond to  slitting  tissues.  The  bis- 
toury, straight  and  pointed,  may  be 
held  in  either  of  these  positions,  but 
it  is  more  frequently  held  as  a  pen 
(Fig.  28),  in  the  opening  of  abscesses,  and  in  the  second  position  in 
dividing  fascia  or  parts  concealed  from  view,  when  for  safety  its 
point  is  carried  along  a  grooved  director  (Fig.  29). 

3.  The  manipulation'  of  the  knife  in  dividing  parts,  whatever  may 

1  Sir  W.  Fergusson;  R.  Liston;  V.  Mott;  F.  C.  Skey. 


Fig.  27. 


THE   OPERATION. 


33 


he  the  fineness  of  its  ad'^a,  must  be  on  the  principle  of  the  saw;  art 
in  the  use  of  the  knife  consists  in  a(hipting  the  requisite  force  to  the 
surface  to  be  divided,  and  the  less  the  pressure  of  the  hand,  pro- 
vided the  edge  be  applied  like  a  saw,  nearly  parallel  to  the  surface 


Fig.  28. 


Fig.  29. 


to  be  divided,  the  more  perfect  will  be  the  wound,  and  when  brought 
into  contact,  the  more  readily  will  it  i-eunite.  In  dissections  re- 
quiring cautious  cutting,  the  knife  should  be  drawn  lightly  and 
steadily  along  the  surface  with  such  force  that  the  divided  textures 
fall  gently  to  each  side,  the  pressure  being  regulated  by  the  nature 
of  the  textures  to  be  cut,  the  proximity  of  important  parts,  and  the 
depth  of  the  wound.  The  bistoury  is  either  carried  completely 
through  the  soft  parts,  dividing  the  fascia  or  sinus  from  its  remote 
extremity  backwards  towards  its  orifice,  or,  if  probe-pointed,  by 
raising  the  blade  out  of  the  groove,  dividing  from  the  orifice  to  the 
remote  end.^ 

4.  The  incision^  may  take  any  form  adapted  to  the  special  operation 
in  hand,  being  single  or  compound,  straight  or  curved,  from  without 
inwards,  or  the  reverse,  but  all  incisions  should,  as  far  as  possible, 
be  made  in  the  line  of  natural  folds  of  the  skin,  and  in  the  course  of 
vessels,  nerves,  muscles,  and  tendons;  when  two  are  made  in  close 
proximity,  the  lower  should  lie  made  first,  to  avoid  the  blood.  The 
precii^e  line  over  which  the  first  incision  is  to  be  made  must  first  be 
determined,  and  its  leu'^th  should  lie  adapted  to  all  the  purposes  of 
the  operation,  being  neither  of  unnecessary  length  nor  so  contracted 
as  to  rcfpiire  subsequent  enlargement.  In  making  the  first  cut,  ren- 
der the  ?kin  tense  over  the  part  without  displacing  its  relations,  then 
'  F.  C.  Skey;  Sir  W.  Fcrgusson;  V.  Mott. 


34  OPERATIVE   SURGERY. 

thrust  the  point  of  the  knife  into  the  integument  at  a  right  angle 
with  the  surface,  depress  the  wrist,  and  incline  the  edge  upon  the 
skin,  make  the  cut  of  the  requisite  length,  and  elevate  the  wrist, 
placing  the  knife  at  nearly  the  same  angle  as  when  it  was  intro- 
duced; if  the  integument  is  very  lax,  this  incision  may  be  made  by 
pinching  up  the  skin,  thrusting  the  knife  through  both  layers,  and 
cutting  outwards.  In  continuing  the  dissection,  make  every  move- 
ment of  the  knife  advance  the  operation  in  an  orderly  manner.  Each 
incision  should  so  far  correspond  in  extent  with  the  first  that  the  deep 
tissues  are  fully  exposed;  when  the  handle  will  sepai'ate  tissues  in 
the  vicinity  of  vessels,  nerves,  or  cavities,  use  it  in  preference  to  the 
blade  ;  raise  fascia  immediately  overlying  important  structures  on 
the  director,  and  then  incise,  unless  perfectly  competent  to  cut  them 
directly  without  risk.  Remove  all  oozing  blood  during  the  opera- 
tion by  absorption  from  time  to  time  with  an  aseptic  sponge.^ 

5.  The  conclusion  2  of  the  operation  must  be  perfe(,'ted  in  every 
detail  with  as  much  cai-e  as  the  first  stages;  there  is  great  danger  to 
the  patient  when  the  operator,  after  he  has  passed  through  the  sort 
of  mental  tension  in  which  he  performs  the  most  difficult  part  of 
what  he  has  to  do,  and  his  attention  has  been  completely  occupied 
in  some  dilHcult  task  to  be  achieved,  allows  his  mind  to  relax  and 
his  attention  to  be  less  keen  and  ready  for  exercise. 


CHAPTER  VII. 

THE  EMERGENCIES. 

Dl'RIXG  every  stage  of  an  operation  there  is  a  liability  to  sudden 
and  dangerous  accidents  and  complications  which  d(;mand  jirompt 
recognition  and  energetic  treatment.  Some  of  these  emergencies 
result  more  or  less  directly  from  the  use  of  ana2sthetics,  while  others 
are  incident  to  the  operation.  A  safeguard  against  the  first  is  the 
selection  of  an  assistant  to  administer  the  ansesthetic  who  is  not  liable 
to  have  his  attention  distracted  by  the  operation,  is  familiar  with  all 
the  phases  of  anaesthesia,  and  is  competent  to  meet  every  indication 
of  care  and  treatment. 

I.  NARCOSIS. 
Narcosis  by  anaisthetics  is  progressive,  and  may  advance  sym- 
metrically or  asymmetrically  ;  that  is,  all  the  vital  functions  may  be 
ecjually  and  uniformly  depressed  to  obliteration,  or  the  narcotic  in- 
fluence may,  in  any  part  of  its  progress,  be  concentrated  upon  some 
one  vital  function,  or  organ,  and  prove  fatal.^  The  most  imjiortant 
1  J.  Lister.  ^  Sir  J.  Paget.  3  £.  i>.  Squiuu. 


THE  EMERGENCIES.  35 

symptom  to  watch  is  tlie  rcsj)iration,  for  if  obstructed  breatliinij  con- 
tiniK'  Idiiir  it  loads  to  fatal  paralysis  of  the  nervous  centres.^  Death 
may  also  commence  at  the  heart,  and  hence  the  pulse  must  also  be 
frecpiently  examined.^ 

1.  Slight  narcosis,  as  irrcirular  respiration,  without  failure  of  the 
pulse,  will  neiurally  yield  to  any  shock,  as  a  slap  on  the  face  with 
a  towel  wet  in  cold  water,  or  forcible  compression  of  the  chest, 
pressure  under  the  ribs  of  the  left  side  in  the  direction  of  the  dia- 
jjhragm,  ammonia  apjilicd  to  the  nostrils,  or  nitrite  of  anivl.^ 

2  Profound  narcosis  is  announced  by  stertor,  impeded  respira- 
tion, pallor,  or  lividity  of  face;  such  symptoms  demand  immediate 
treatment.  Two  methods  of  resuscitation  are  stronirly  recommended, 
iiotli  of  which  can  always  be  instantly  aj)plied.  The  first  ^  is  based 
on  the  theory  that  respiration  ceases  from  laryngeal  paralysis,  which 
is  indicated  by  stertor,  and  may  be  relieved  by  very  forcible  with- 
drawal of  the  tongue  ;  artery  forceps,  or  a  tenaculum,  are  the  best 
instruments:  in  order  that  it  may  be  effectual,  firm  traction  is  essen- 
tial ;  the  end  of  the  organ  may  be  withdrawn  consideraljly  beyond 
the  lijis  without  any  good  effect,  but  if  an  additional  pull  be  given, 
the  nervous  system  is  aroused  and  respiration  reestablished.  The 
second  method  *  consists  in  inversion  of  the  body,  with  a  view  to 
overcome  supposed  cerebral  anaemia,  as  follows  :  suspend  the  body 
with  the  head  downward  by  elevatiug  the  thighs  or  hips,  or  by  al- 
lowing the  body  to  hang  from  the  side  of  the  table ;  separate  the 
jaws,  and  draw  the  tongue  forcibly  forward  ;  agitate  the  body,  and 
practice  artificial  respiration  ;  persevere  in  maintaining  the  patient 
ill  this  position  for  thirty  minutes  or  more,  if  necessary. ^ 

3.  Apncea  from  regurgitation  of  the  contents  of  the  stomach  into 
the  lungs  occasionally  occurs,*'  and  requires  prompt  treatment  by  the 
direct  method^   of  treating  persons  suffering  from  drownin<^. 

To  relieve  the  liinj^s  of  the  fluids,  proceed  as  follows:  — 

Face  (lownv.ards ;  a  hard  roll  of  clothing  beneath  the  epigastrium,  making 
that  the  highest  point,  the  mouth  the  lowest  ;  forehead  resting  upon  forearm  or 
wrist,  keeping  mouth  from  the  ground;  place  the  left  hand  well  spread  upon 
base  of  thorax  to  left  of  spine,  the  right  hand  upon  the  spine  a  little  below  the 
left,  and  over  lower  part  of  stomach;  throw  upon  them  with  a  forward  motion 
all  the  Aveight  and  force  the  age  and  sex  of  patient  will  justify,  ending  this 
pressure  of  two  or  three  secon<ls  with  a  sharp  push,  which  helps  to  jerk  you 
back  to  the  upright  position.  Itcpeat  this  two  or  three  times,  according  to  pe- 
riod of  submersion  and  other  indications. 

Artilicial  respiration  is  produced  as  follows,  whenever  it  is  required  :  Face 
upwards;  the  hard  roll  of  clothing  beneath  thorax,  with  shoulders  slightly  de- 

'  J.  Lister.        -  T.  Holmes.        3  p.  a.  Rikhall.        *  Nt51aton  ;  Schuppart. 
5  J.  M.  Si.MS.  c  Bellevue  Hospital  Kecords.  "  B.  Howard. 


36 


OPERATIVE  SURGERY. 


clinins  over  it ;  head  and  neck  bent  back  to  the  utmost.  Hands  on  top  of  head; 
(one  twist  of  handkerchief  around  the  crossed  wrists  will  keep  them  there);  rip 
or  strip  clothing  from  waist  and  neck;  kneel  astride  patient's  hips;  place  j-our 


hands  upon  his  chest,  so  that  the  ball  of  each  thumb  and  little  finger  rests  upon 
the  inner  margin  of  the  free  border  of  the  costal  cartilages,  the  tip  of  each 
thumb  nearer  upon  the  xiphoid  cartilage,  the  fingers  fitting  into  the  correspond- 
ing iuiercostal  spaces  ;  fix  your  elbows  firmly-,  making  them  one  with  your 
sides  and  hips  ;    then  — 

Pressing  upwards  and  inwards  towards  the  diaphragm,  use  your  knees  as  a 
pivot,  and  throw  your  weight  slowly  forwards  two  or  three  seconds  until  your 
face  almost  touches  that  of  the  patient,  ending  with  a  sharp  push  which  helps  to 
jerk  you  back  to  your  erect  kneeling  position.  Rest  three  seconds  ;  then  repeat 
this  bellows-blowing  movement  as  before,  continuing  it  at  the  rate  of  seven  to 
ten  times  a  minute  ;  taking  the  utmost  care,  on  the  occurrence  of  a  natural  gasp, 
gently  to  aid  and  deepen  it  into  a  longer  breath,  until  respiration  becomes  nat- 
ural. When  practicable,  have  the  tongue  held  lirnily  out  of  one  corner  of  the 
mouth  with  thumb  and  finger  armed  with  dry  cotton  rag.  Avoid  impatient  ver- 
tical pushes;  the  force  must  be  upward  and  inward,  increased  gradualh'  from 
zero  to  the  ma.ximum  as  the  age,  sex,  etc.,  may  indicate.  Abandon  no  case 
as  hopeless  within  an  hour's  useless  effort. 

The  followinn;  methods  may  be  employed  :  1,  lay  the  patient  on  his 
back,  Avith  the  shoulders  elevated,  draw  the  tongue  forcibly  forwards, 
grasp  the  arms  at  the  elbow  and  carry  them  upwards  firmly  until 
they  nearly  meet  above  his  head,  then  lower  them  to  the  side,  and 
make  firm  compression  upon  the  lower  part  of  the  sternum;  repeat 
this  process  twelve  to  fourteen  times  in  the  minute. ^  Or  2,  turn  the 
body  gently  and  completely,  on  the  side  and  a  little  beyond,  and 
then  on  the  face,  alternately;  repeating  these  measures  deliberately, 
efficiently,  and  perseveringly,  fifteen  times  in  a  minute. - 

Meantime  other  measures  should  not  be  neglected,  as  external 
stimulants,  the  application  of  the  poles  of  tlie  battery  to  the  vicinity 
of  the  diaphragm  in  front  and  the  cervical  region  behind. 


1  Sylvester. 


2  M.  Hall. 


THE  EMERGENCIES.  37 

11.  BLKKDIXG. 
It  not  unfrequently  hajiiR-ns  that  profuse  blecfling  occurs  from 
many  vessels,  to  which  the  oj)erator  cannot  apply  the  lijifature  with- 
out losing  valuable  time.  This  complication  must  be  promptly  met 
by  compression  of  the  cut  vessels  by  the  fingers  of  an  assistant, 
aitled  by  dry  sponges  or  a  towel,  to  which  ice  may  be  added;  a 
skillful  assistant  may  thus  cover  the  exposed  vessels  of  a  large  sur- 
face as  the  dij^section  proceeds.^ 

III.  SHOCK. 

Severe  rotlox  disturbance  or  paralysis  of  nerve  centres  is  liable 
to  supervene  towards  the  close  of  an  operation,  especially  on  a 
sudden  loss  of  blood,  when  the  operator  is  least  prepared  to  encoun- 
ter so  formidable  a  complication.  In  general,  it  is  remarkable  how 
little  impression  is  produced  by  even  the  most  severe  operations, ■^ 
and  hence  the  surprise  which  the  discovery  of  the  presence  of  sliock 
creates.  The  patient  often  passes  suddenly  from  a  state  of  proper 
ansesthesia,  and  without  any  additional  aniesthetie,  to  a  condition  of 
more  or  less  profound  shock.  There  is  no  warning  of  its  approach, 
and  the  first  impression  is  that  too  much  of  the  anassthetic  has  been 
given. 3  This  is  not  narcosis  from  anaesthesia,  but  shock.  The 
degree  of  prostration  depends  somewhat  upon  the  previous  condi- 
tion of  the  patient  and  the  nature  of  the  disease,  but  more  mark- 
edly ujwn  the  degree  of  shock  from  the  injury  which  gave  rise  to 
the  operation,  the  amount  of  blood  lost,  and  the  length  of  the  opera- 
tion. The  bodily  temperature  and  pulse  are  the  best  guides  to  de- 
termine the  severity  and  danger  of  shock,  and  ought  to  be  noted, 
first,  before  the  operation,  and  second,  during  and  after  the  opera- 
tion; variations  not  accounted  for  by  obvious  causes  will  indicate 
the  effect  of  the  operation,  and  often  give  timelv  warning  of  impend- 
ing danger.  In  an  average  of  cases  of  operations,  recoveries  have 
a  fall  of  temperature  of  less  than  one  degree,  and  deaths  of  more 
than  three  degrees,  a  fall  below  97^  F.  is  very  critical,  but  recover- 
ies except ioiially  occur.* 

1.  Syncope  may  be  regarded  and  treated  as  an  early  stage  of  col- 
la[)se.  These  conditions  differ  only  in  degree  and  duration.*  In 
the  former  the  crisis  is  more  rapid  and  in  the  latter  the  effects  are 
more  extensive  and  profound.^  The  symptoms  are  pallor,  sighing 
respiration,  feeble  pulse,  and  other  symptoms  of  great  prostration. 
The  indications  of  treatment  arc  to  arouse  the  nervous  system  liy 
stimulation;  place  the  head  low,  apply  vapor  of  ammonia  cautiously 

1  .1.  R.  Wood.  -  O.  W.  (^allender.  s  .1.  Croft. 

■*  F.  Jonnlaii.  S  li.  'I'laveis.  6  \V.  6.  Savory. 


38  OPERATH^  SURGERY. 

to  the  nostrils,  give  brandy  by  the  mouth  or  rectum,  or  inject  it 
hypodermically,  and  apply  external  warmth  and  irritants;  in  extreme 
cases  use  electricity  ;  or  intravenous  injections  of  milk.^ 

2.  Collapse  may  rapidly  succeed,  with  the  additional  symptoms 
of  cold,  clammy  moisture  of  skin,  and  often  distinct  drops  of  sweat 
upon  the  brow,  shrunken  and  contracted  features,  reduced  bodily 
temperature,  almost  imperceptible  and  often  irregular  pulse,  short 
and  feeble  or  panting  respiration.  Tlie  treatment  of  collapse  may 
require,  in  addition  to  the  measures  employed  in  syncope,  transfu- 
sion if  there  has  been  great  loss  of  blood.  As  the  most  unfavorable 
cases  will  frequently  recover  if  energetically  treated,  the  efforts  at 
restoration  should  not  be  relaxed  until  recovery  is  secure,  or  death 
has  occurred.  If  reaction  begin,  stimulation  should  in  part  give 
place  to  nutrition;  the  patient  must  remain  in  the  horizontal  posi- 
tion; beef-juice,  with  brandy,  should  be  given  at  first,  and  milk 
should  soon  be  added  ;  sub-cutaneous  injections  of  morphia  are  very 
imjiortant  in  securing  rest  and  cjuiet;  or  if  it  cannot  be  taken,  hyos- 
cyamus  may  be  combined  or  substituted. 

lY.  AIR  IN  THE  VEINS. 
A  wound  of  a  vein  is  liable  to  admit  air  to  the  circulation;  it 
occurs  during  dissection  in  tlie  vicinity  of  large  veins,  as  in  the  neck 
or  axilla;  the  vein  having  been  wounded,  slight  traction  of  parts 
during  inspiration  allows  the  air  to  enter  the  current  of  blood. 
Sooner  or  later  it  arrives  at  the  right  side  of  the  heart,  passes  the 
valves,  enters  the  ventricle,  and  remains  there,  dilating  by  its  elas- 
ticity the  ventricular  walls;  this  distention  may  take  place  slowly, 
but  it  is  constant,  often  doubling  or  tripling  the  normal  size  of  the 
right  heart;  from  this  distention  it  results  that  (1)  the  contractile 
force  remaining  the  same,  and  the  resistance  augmentinii,  the  au- 
riculo-ventricular  contraction  becomes  more  and  more  incomplete; 
(2)  the  walls  contracting  on  a  gas  instead  of  a  liquid  compress  it 
without  driving  it  out;, (3)  the  orifices  of  the  right  side  remaining 
patulous,  the  foaming  mixture  of  blood  and  air  regurgitates  into 
the  veins  and  is  carried  to  the  most  distant  parts  of  the  system; 
this  reverse  current  persists  until  the  distention  passes  certain  limits, 
when  death  results.^  The  symptoms  are  a  peculiar  sound  at  the 
bottom  of  the  wound  like  gurgling,  hissing,  or  bubbling;  a  slight 
issue  of  venous  blood,  and  often  bubbles  of  air;  the  patient  sud- 
denly turns  pale,  utters  a  cry,  and  becomes  insensible,  or  there  is 
anxiety  of  countenance,  labored  respiration,  lividity  of  lips,  dilated 
pupils,  and  convulsions;  syncope  is  often  the   predominant  feature, 

1  See  Veins.  2  jx.  Gouty. 


THE  DRESSIXG.  39 

and  tlie  patient  may  die  with  scarcely  a  struggle.  The  symptoms 
are  developed  according  to  the  following  conditions:  (1)  diminution 
of  the  aortic  contents  and  loss  of  arterial  tension,  with  acceleration 
of  the  heart,  but  no  general  symptoms  ;  (2)  more  considerable  loss  of 
tension  and  accelerated  respiration,  with  syncope,  paleness,  dilata- 
tion of  pupils ;  (3)  Aortic  current  little  or  nothing,  and  excitation  of 
the  motor  centres,  with  convulsive  movements  of  the  voluntary  nuis- 
cles,  involuntary  defecation  and  mictiuition,  resjjiration  slow,  deep, 
apoplectic;  (4)  no  arterial  tension,  death  of  the  brain,  with  cessation 
of  convulsions,  then  arrest  of  respiration,  and.  finally,  stoppage  of 
the  heart's  action.^  The  treatment  must  be  prompt  and  persistent, 
in  the  following  order:  (1)  prevent  ingress  of  air  by  instantly  pressing 
the  point  of  the  index  finger  upon  the  spot  whence  the  sound  pro- 
ceeds ;  tie  the  vein  at  once,  or  finish  the  operation  without  removing 
the  finger,  or  while  firm  compression  is  made  on  the  vein  on  the  prox- 
imal side  of  the  wound;  (2)  remove  the  air  already  admitted  by  ar- 
tificial respiration;  (3)  sustain  the  vital  organs  as  in  profound  syn- 
cope, by  chafing  the  limbs,  applying  ammonia  to  the  nostrils,  injec- 
tions of  brandy  hypodermically  or  by  the  rectum,  and  the  employ- 
ment of  fralvanisni. 


CHAPTER  VIII. 

THE   DRESSING. 

It  is  not  alwaj-s  possible  to  secure  the  repair  of  wounds  by  the  best 
method  of  healing,  yet  the  surgeon  is  culpable  who  does  not  make 
all  needful  efforts  to  obtain  in  each  case  the  best  attainable  results. 
One  of  the  most  imi)ortant  factors  in  the  successful  healing  of  a 
wound  is  the  management  of  the  dressings,  but  in  order  to  their 
proper  employment  the  condition  of  the  cut  surfaces  and  the  primary 
stages  of  repair  must  be  understood. 

I.  PRINCIPLES  OF  DRESSING.2 
Mechanical  irritation  resulting  from  the  passage  of  the  instruments 
through  the  parts  appears  to  throw  a  thin  layer  of  the  tissues  at  the 
cut  surface  into  a  condition  of  suspemled  vital  activity,  in  which,  the 
normal  relations  between  the  blood  and  the  living  solids  being  inter- 
rupted, the  minute  vessels  become  cloggeil  with  the  blood  corpuscles, 
and  coagulable  plasma  is  forced  through  their  parietes  and  fiows  out 
upon  the  surface  of  the  wouml;  the  filirine  of  the  coagulating  plasma 
forms  the  lymph  whirh  encrusts  the  cut  surface,  while  its  other  and 

1  J.  S.  Greene.  *  J.  Lister. 


40  OPERATIVE  SURGERY. 

farlar^rer  constituent,  the  serum,  trickling  away  between  the  lips  of  the 
wound,  shows  itself  as  the  discharge  which  soaks  the  dressings  during 
the  first  twenly-four  hours;  the  original  source  of  irritation  being  no 
lono'er  in  ojjcration,  the  tissues,  if  free  from  any  disturbing  cause,  are 
gradually  recovering  their  powers  by  virtue  of  their  inherent  vital 
energy,  and  as  they  regain  their  functions  the  effusion  of  plasma 
ceases,  and  a  process  of  active  organization  is  instituted,  by  which 
the  lymph  is  differently  affected  according  to  circumstances.  If  the 
surfaces  of  the  wound  are  in  juxtaposition,  the  lymph  glues  them 
together,  and,  being  surrounded  on  all  sides  by  healthy  tissue,  be- 
comes developed  in  a  few  days  into  a  vascular  structure  which  con- 
stitutes a  permanent  bond  of  union  between  them  ;  but  if  tlie  surfaces 
are  separated  by  serum,  pent  up  in  the  interior,  immediate  union  is 
prevented,  and  the  serum,  putrefying  through  atmospheric  influence, 
irritates  the  tissues  and  gives  rise  to  suppuration;  or  if  serum  be  not 
retained  but  some  persistent  local  irritation  be  present,  such  as  the 
dragging  of  stitches  upon  an  insufficient  covering  of  soft  parts,  or  a 
tightly  constricting  bandage,  inflammation  will  be  induced,  and  in 
proportion  to  its  degree  will  interfere  with  the  process  of  organic  de- 
velopment, and  convert  what  promised  primary  union  into  suppura- 
tion; or  if  more  severe,  render  the  lips  of  the  wound  entirely  inactive 
and  incapable  of  producing  even  pus;  or,  if  still  more  intense,  deprive 
them  of  their  vitality  and  cause  sloughing;  thus  while  the  effusion 
of  the  lymph  which  is  the  medium  of  primary  union  depends  upon 
a  species  of  traumatic  inflammation,  the  healthy  organization  of  that 
lymph  requires  the  absence  of  any  inflammation  whatever,  and  the 
great  object  of  treatment  must  be  to  place  the  wound  in  such  cir- 
cumstances that  the  tissues  may  be  left  undisturbed  to  recover  from 
the  shock  they  have  sustained,  and  then  exert  their  powers  upon  the 
product  of  their  derangement.  The  following  simple  rule  is  of  uni- 
versal application,  namely:  Let  the  dressing  be  destitute  of  any  irri- 
tating quality,  and  so  arranged  that  the  surfaces  of  the  wound  may 
be  kept  in  gentle  apposition  throughout  if  closed,  and  free  from  all 
irritants  if  open,  while  free  escape  of  discharge  is  maintained. 

II.    PREPARATION  OF  WOUND. 

To  secure  the  conditions  favorable  for  healing,  it  is  necessary  to 
remove  every  source  of  contamination  from  the  wound,  and  then 
protect  it  from  all  unfavorable  influences. 

1.  The  cleansing  nuist  be  effected  by  such  means  as  will  relieve  the 
wound  of  evei-y  particle  of  foi-eign  matter  and  shred  of  dead  tissue, 
and  render  inert  or  innocuous  any  putrefactive  organisms  which  may 
still  adhere  to  the  surface,  but  great  care  must  be  exercised  in  order 
not  to  injure  the  sensitive  tissues  in  this  act.     Cleansing  and  disin- 


THE  DRESSING.  41 

fection  may  usually  be  most  readily  and  thoroughly  accnmpli-hed  by 
solutions  f)f  carbolic  acid,  1  in  20,  applied  by  irrigation  with  the 
siphon  or  with  the  syrinirc. 

2.  The  drainage  ot  a  wound  is  next  in  iniportancc«to  the  avoidance 
of  putrefaction,  for  if  the  ei'fiisud  jdasnia  is  allowed  to  accuni'.datc  it 
is  likely  to  create  intlanimalion  by  its  tension,  and  also  to  undergo 
putrefactive  changes.^  The  materials  used  for  drains  must  be  of  an 
unirritating  quality,  and  be  rendered  aseptic  by  carbolic  acid  before 
their  introduction.  The  caoutchouc  tube  "^  is  useful  where  it  is  not 
liable  to  such  compression  as  to  close  its  calibre  ;  select  a  tube  of 
the  proper  size,  and  cut  it  of  the  requisite  length,  also  cut,  with 
scissors,  several  holes  along  its  sides  to  allow  the  free  escape  of  the 
fluid  into  Its  interior,  attach  a  string  to  its  external  extremity,  dip  it 
in  carbolic  acid  solution,  1  to  20,  and  insert  it  to  the  bottom  of  the 
wound;  remove  it  from  time  to  time,  cleanse,  disinfect,  and  re-intro- 
duce. Catgut  3  drains  well  and  is  finally  absorbed,  rendering  fre- 
(pient  removal  unnecessary,  but  may  swell  too  much,  and  become  so 
incorporated  with  the  tissues  as  to  cause  bleeding,  if  removed. ^ 
llorse-hair^  makes  a  cheap  and  efficient  drain,  and  has  the  great 
advantage  that  it  can  be  reduced  in  bulk  at  any  time  without  disturb- 
ance, by  drawing  out  as  many  hairs  as  may  be  desired  ;  the  hair 
should  be  treated  with  carbolic-acid  solution,  1  to  20,  and  may  be 
introduced  with  forceps,  or  with  the  eye  of  a  probe  ;  it  may  be  re- 
moved in  whole  or  in  part  by  withdrawing  one  hair  after  another  ; 
if  it  is  necessary  to  re-introduce  the  drain,  take  a  wisp  of  hair  half 
the  size  required,  l>end  it  in  the  middle  at  a  .'^harp  angle  over 
the  probe,  tie  a  piece  of  carbolized  silk  around  it  close  to  the  probe, 
on  withdrawal  of  which  the  drain  is  left  with  a  rounded  end  which 
j)asses  readily  into  the  interior  of  the  wound.* 

;j.  The  position  of  the  wound  must  be  such  as  to  favor  the  escape 
of  all  secretions,  to  ])romote  the  free  circulation  of  blood,  and  to  re- 
lieve the  wound  of  all  sources  of  irritation.  The  wound  will  thus  be 
so  ])laced  as  to  secure  perfect  rest,  the  necessary  antecedent  to  the 
healthy  accomplishment  of  both  repair  and  growth.* 

III.  ANTISEPTIC  DRESSING. 
This  method  is  designed  to  exclude  from  wounds  all  putrefactive 
or.Mnisms.*  Though  the  antiseptic  treatment  of  surgical  diseases  is 
infinite  in  variety,  extending  from  the  sim|>le  protection  of  wounds 
from  contact  of  catalytic  germs,  to  the  purification  of  hospital  wards, 
water-closets,  and  grounds,"  but  two  principal  methods  of  employing 
antiseptic  dressings  are  in  use;   first,  by  dis-infecting  the  wound  and 

1 ,'.  LisTi:i«.  2  li.  Cliassaifrnac.  8  J.  Chiene.  <  L.  W.  Marshall 

6  J.  Hilton.  «  J.  H.  Hodgen. 


42  OPERATIVE  SURGERY. 

the  air  about  the  wound  with  antiseptic  agents;  second,  by  intercepting 
septic  niattei's  around  an  already  disinfected  wound.  The  antiseptic 
agents  are  very  numerous,  embracing  the  haloid  salts,  the  tar  creo- 
sotes, the  antiperiodics,  yet  they  are  not  all  equally  applicable  for 
general  use. 

I.  Carbolic  acid^  has  proved,  thus  far,  the  most  available  antisep- 
tic agent,  as  it  may  at  once  be  used  for  disinfecting  the  wound  and 
the  air,  and  for  storage  in  the  dressings.  Though  useful,  however 
superficially  but  judiciously  used,  its  full  benefit  is  secured  only  when 
it  is  employed  iu  a  systematic  manner,  with  an  intelligent  apprecia- 
tion of  the  objects  sought  to  be  accomplished  at  each  step  in  the 
dressing.  The  following  are  the  details  when  the  dressing  is  applied 
according  to  the  foi'mula :  Provide  a  vessel  containing  carbolic  acid 
dissolved  in  water,  1  to  40,  for  the  immersion  of  the  hands  of  the 
operator,  the  sponges  and  instruments  used  in  the  wound  ;  a  steam 
spray  apparatus,  capable  of  giving  a  cloud  of  vapor  (make  the  solu- 
tion of  carbolic  acid  to  be  atomized  1  to  30,  which  diluted  by  the 
steam  will  give  a  1  to  40  spray)  ;  antiseptic  gauze,  oi)en  cotton  cloth 
impregnated  with  carbolic  acid  1  part,  common  resin  5  parts,  and 
parafline  7  parts  ;  Mackintosh  (fine  cotton  hat  lining),  or  gutta  per- 
cha  tissue  of  good  quality  will  also  answer,  but  is  liable  to  wear  into 
holes  ;  drainage  tubes  (India  rubber,  with  a  silk  ligature  attached, 
or  horse-hair ;)  oiled  silk  protective  (oiled  silk  coated  on  both  sides 
with  copal  varnish,  and  afterward  brushed  over  with  dextrine; 
when  the  copal  varnish  has  dried,  a  mixture  of  one  part  of  dextrine, 
two  parts  of  starch,  and  sixteen  parts  of  carbolic  acid  is  brushed 
over;  the  acid  soon  evaporates  ;  common  oiled  silk,  smeared  with 
the  oily  solution,  will  answer  the  purpose  pretty  well,  especially  if 
used  in  two  layers;)  carbolized  catgut  ligatures.  Proceed  as  follows: 
Shave  the  part,  if  there  is  much  hair,  in  order  that  the  antiseptic  may 
not  be  prevented  from  acting  upon  the  skin  ;  wash  the  part  witli  a 
watery  solution,  1  to  20,  to  purify  the  skin;  direct  the  spray  upon 
the  part  and  maintain  its  action  and  position  during  the  entire 
operation  and  dressing,  without  a  moment's  interval;  immerse  the 
hands,  instruments,  and  sponges  in  the  1  to  20  solution  before 
operating,  and  at  every  interval  when  not  envelojjed  by  the  spray  in 
the  1  to  40  solution;  tie  all  vessels  with  antiseptic  catgut  and  cut 
the  ligatures  at  the  knot  ;  if  the  finger  is  to  be  introduced  into  the 
wound,  take  s])ecial  care  that  it  is  an  aseptic  finger,  and  this  is 
ilone  by  cleansing  it  with  an  antiseptic  solution,  making  sure  that  it 
passes  well  into  the  folds  about  the  nail;  instruments  must  remain  in 
the  antiseptic  lotion  sufficiently  long  to  penetrate  any  dirt  or  grease 
which  may  be  concealed  on  them,  as  between  the  teeth  of  forceps; 
sponges,  though  used  in  suppurating  wounds,  but  thoroughly  treated 

1   J.  LiSTKK. 


THE  DRESSING.  43 

with  carbolic  acid  solution,  are  antiseptically  clean.  First,  wash 
the  cut  surface  thoroughly  with  a  strong  watery  solution,  1  to  20; 
jilace  the  drainage  tube  or  tubes  so  deeply  in  the  wounds  as  to  drain 
all  accuimdaliiig  fluids.  The  effusion  of  plasma  which  occurs  during 
the  first  few  hours  after  the  infliction  of  a  wound  is  greater  when 
the  cut  surface  has  been  treated  with  a  stimulating  wash  than  it  is 
under  ordinary  management,  and  unless  provi.-ion  be  made  for  its 
escape,  it  will  be  pretty  sure,  in  a  wound  of  considerable  deptli,  to 
accumulate  in  suflicicnt  (juantity  to  cause  inflammatory  disturbance 
from  tension.  When  the  antiseptic  has  left  the  wound  the  discharge 
will  be  trifling  in  amount,  unless  the  irritation  is  continued  by  blood 
or  serum  pent  up  in  sufficient  (pantity  to  cause  disturbance,  or  by 
some  other  accidental  circumstance  exciting  the  nerves  of  the  part. 
If  the  tube  enters  obliquely,  cut  the  outer  extremity  obliquely;  lay  the 
retaining  threads  on  the  surface;  if  the  wound  is  to  be  closed  as  after 
amputation,  use  carbolized  silk  for  sutures,^  as  it  is  very  superior  to 
wire,  not  only  on  account  of  its  perfect  suppleness,  but  because  its 
actively  antiseptic  character  insures  absence  of  putrefaction  in  the 
track  of  the  wound  ;  the  spray  is  never  more  useful  than  in  the  in- 
troduction of  the  sutures;  if  it  be  not  employed  the  wound  must  be 
injected  with  lotion  after  the  insertion  of  the  last  stitch,  to  destroy 
any  mischief  that  may  have  entered  through  regurgitation  of  blood 
that  oozes  into  the  cavity  during  the  sewing;  if  strap[)ing  is  re(juired 
common  adhesive  plaster  may  be  rendered  antiseptic  by  dipjjing  it 
for  a  second  or  two  in  a  watery  solution  of  the  acid,  and  it  is  most 
convenient  to  have  the  lotion  hot ;  tlie  ends  should  be  overlapped  by 
the  gauze;  apply  to  the  cicatrizing  part  a  layer  of  the  oiled  silk  pro- 
tective, wet  with  the  watery  solution,  and  having  a  hole  for  tlie  drain- 
age-tube, for  cicatrization  is  retarded  when  the  acid  is  allowed  to 
act  immediately  on  the  margins  of  the  wound,  and  it  is  therefore 
necessary  to  protect  the  part  by  interposing  between  it  and  the 
gauze  a  layer  of  some  impermeable  material;  apply  eii^ht  layers 
of  the  gauze,  of  such  size  as  to  cover  all  the  wound  and  the  adjacent 
parts;  in  situations  where  there  is  not  as  much  extent  of  skin  for  the 
gauze  to  overlap  as  is  desirable,  as  in  the  vicinity  of  the  pubes,  the 
deficiency  of  surface  may  be  compensated  by  using  the  gauze  in  a 
thicker  mass,  say  in  sixteen  or  thirty-two  layers;  dip  the  first  layer 
in  the  solution,  for  if  the  gauze  were  applied  dry,  some  active  septic 
particle  adhering  to  its  surface  might  enter  the  blood  or  serum  at  the 
outlet  of  the  wound,  and  propagate  putrefaction  to  the  interior;  be- 
tween the  last  two  layers  ])lace  a  piece  of  Mackintosh  of  smaller  size 

1  Sillv  tliread  willi  tlic  interstices  among  the  fifires  fiiied  up  with  wax  con- 
taining at)niit  a  tenth  part  of  earbolic  acid;  mix  the  acid  with  molted  beeswax; 
iinmerse  the  sill<,  and  wlien  tlioroughly  steeped  draw  it  out  through  a  cloili  to 
remove  superfluous  wax. 


44  OPERATIVE  SURGERY. 

than  the  layers  of  gauze  ;  apply  the  last  layer  so  as  to  cover  in  com- 
pletely the  JMackintosh  ;  this  impermeable  cloth  is  used  to  prevent 
the  discharge  from  going  directly  through  the  dressing,  because,  if 
a  considerable  (quantity  went  through,  the  acid  might  all  be  washed 
out  within  twenty-four  hours,  and  then  putrefaction  would  spread 
inwards  to  the  wound  ;  the  Mackintosh  having  no  antiseptic  prop- 
erty, except  mechanically  by  its  impermeability,  but,  on  the  con- 
trary, being  like  other  indifferent  materials  covered  more  or  less 
with  septic  matter,  it  is  necessary  when  the  dressing  consists  of 
more  pieces  than  one,  that  the  Mackintosh  be  well  covered  in 
at  the  place  of  junction  of  the  two  pieces,  for  if  it  were  allowed 
to  j^roject  uncovered  in  the  vicinity  of  the  wound  it  might  com- 
municate septic  mischief  ;  retain  the  dressings  by  bandages  of  the 
antiseptic  gauze,  over  which  elastic  webbing  may  be  applied  when 
the  bandage  is  not  sufficient,  as  in  wounds  or  abscesses  in  the 
groin  ;  inspect  the  wound  on  the  day  after  its  infliction,  whether 
it  be  accidental  or  the  result  of  operation,  and  change  the  dressing 
only  in  case  the  discharge  is  liable  to  extend  beyond  the  edge  of  the 
folded  o-auze;  during  the  subsequent  progress  of  the  case  leave  the 
gauze  undisturbed  for  periods  varying  from  two  days  to  a  week,  ac- 
cording to  the  diminution  of  the  effusion;  in  re-dressing  continue  the 
spray  uninterruptedly  on  the  part ;  while  the  bandage  is  being  cut 
or  removed,  the  patient,  or  an  assistant,  keeps  his  hand  over  the  site 
of  the  wound,  to  prevent  the  dressing  from  rising  en  masse,  and 
pumping  in  septic  air;  in  raising  the  folded  gauze  take  care  that  the 
spray  jiasses  into  the  angle  between  it  and  the  skin  ;  remove  the 
drainage-tubes,  cleanse  them  in  the  carbolic-acid  solution,  and  before 
re-introducing  them  cut  off  such  portions  as  the  granulations  in  the 
wound  render  necessary  to  bring  the  external  extremity  flush  with  the 
surface  of  the  skin;  lay  aside  the  gauze  which  is  soaked,  but  use 
the  Mackintosh  again  after  cleaning  it  with  carbolic-acid  solution.! 

2.  Cotton-wool  2  is  used  to  intercept  germs  in  the  air.  Apply  it 
as  follows  to  open  wounds,  as  after  amputation:  Select  three  or  four 
pounds  of  wool  of  good  quality,  white  and  clear  of  foreign  matters; 
strip  off  any  glazed  surface  ;  tear  the  sheets  into  strips  about  one 
foot  wide,  and  roll  them  up;  prepare  several  rolled  bandages  of  un- 
washed linen  or  cotton,  two  inches  wide  and  eight  to  ten  yards  long; 
remove  the  patient  from  a  septic  atmosphere,  as  that  of  a  ward, 
during;  the  dressing;  apply  ligatures  to  all  bleeding  points;  wash  the 
wound  with  a  solution  of  carbolic  acid  (one  per  cent)  ;  the  wound 
being  held  open,  fill  it  completely  with  little  wads  of  loose  cotton- 
wool evenly  superposed;  now  apply  the  rollers  of  cotton-wool  over 
and  around  the  limb  evenly  and  methodically,  so  as  to  surround  it 
with  a  homogeneous  mass  of  even  thickness,  which  must  in  all  eases 
1  J.  Lister.  "-  A.  Gueriu;  T.  B.  Ccuris. 


THE  DRESSING.  45 

extend  beyond  the  first  joint  above  the  seat  of  the  wound.  Apply 
roller  after  roller  of  the  wool  so  long  as  strong  pressure  throufdi  the 
mass  gives  any  pain;  next  ap|)ly  the  common  bandage  fur  the  pur- 
pose of  seenrin;^  the  wool,  the  turns  being  up  and  down  the  limb, 
circular,  oblique,  or  s])iral,  as  will  best  mould  the  mass  into  shape; 
wherever  there  is  any  bulging  the  bandage  should  be  applied,  the 
end  being  ecjually  compressed  with  the  sides  ;  thus  oraduallv  cover 
the  wool  at  every  point  by  successive  over-laj)ping  of  the  bandafre, 
making  each  roller  firmer  and  firmer  as  the  ap"^)licati()n  pro'_'resses, 
the  last  being  applied  with  all  the  power  of  the  strongest  hands; 
place  the  patient  in  bed;  lay  the  limb  on  a  folded  sheet  and  cover 
with  a  cradle.  If  the  case  progress  favorably,  the  dressings  should 
not  be  disturbed  for  two  or  three  weeks,  except  they  become  loos- 
ened, when  additional  layers  of  bandage  should  be  applied  to  secure 
anew  the  firm  consistency  and  elastic  compression  of  the  fre.-hly 
applied  dressing.  On  the  fifteenth  or  twentieth  day  remove  the 
bandages,  and  tear  open  the  cotton-wool,  layer  by  layer,  along  the 
anterior  aspect  of  the  wound.  The  wound  will  be  found  granulating 
in  a  healthy  manner,  the  bone  being  well  covered,  and  the  limb  as 
natural  as  at  the  time  of  the  operation.  The  further  treatment  is 
that  of  an  open  granulating  sore.  Throughout  the  treatment  the 
dressings  must  be  watched  to  detect  signs  of  hipmorrhage,  and  the 
temperature  must  be  taken  for  evidences  of  imjjending  or  existing 
erysipelas,  septicivmia,  and  pyaemia. 

lY.   ORDINARY  DRESSINGS. 

The  special  form  of  dressing  must  be  determined  by  the  nature,  con- 
ditions, and  peculiarities  of  each  individual  wound,  and  the  method 
of  repair  which  is  sought  to  be  obtained.  In  treatment,  wounds  are 
either  closed  or  open;  the  former  tend  to  primary  union,  the  latter 
to  secondary  union,  or  union  by  granulation.  Although  the  mor- 
phological changes  in  the  tissues  are  the  same  in  both  cases,*  the 
method  of  closing  wounds  immediately  after  an  operation  is  to  be 
preferred  whenever  the  conditions  are  favorable  to  primary  union, 
as  the  wound  heals  more  rapidly,  with  less  inflammation,  and  gives 
more  perfect  results,  especially  Avhen  immediate  union  is  secured, 
which  is  the  best  imaginable  process  of  healing.^ 

The  subcutaneous  wound  must  be  carefully  protected  from  the 
admission  of  air  to  the  interior,  as  follows:  On  the  withdrawal  of 
the  knife,  press  the  end  of  the  finger  firmly  upon  the  cut,  then  apply 
an  adhesive  strip  over  the  wound,  upon  this  place  a  mass  of  cotton 
batting  anil  retain  it  with  adhesive  j)laster  ;  re-dressinf  is  not  re- 
quired until  the  union  is  complete,  unless  suppuration  occur.  Incised 
1  T.  Billroth.  2  Sir  J.  Paget. 


46  OPERATIVE  SURGERY. 

wounds  repair  by  primary  union,  when  their  surfaces  are  accurately 
maintained  in  apposition  without  the  intervention  of  any  unorganiza- 
ble  matter,  and  should  be  treated  with  a  view  to  such  union,  unless 
the  conditions  make  it  desirable  that  repair  should  be  by  granulation. 

1.  Collodion  is  the  best  application  if  the  wound  is  very  superficial 
and  does  not  gape  ;  or  gauze  may  be  added  to  give  more  support,  as 
follows  :  Cut  strips  one  or  two  inches  wide,  and  three  or  four  inches 
long,  and  with  a  camel's-hair  brush  moisten  one  end  of  the  strip, 
which  quickly  dries  and  adheres  ;  then  treat  the  other  in  the  same 
manner;  when  the  wound  is  covered  with  the  gauze,  apply  the  col- 
lodion freely  over  the  whole  material,  thus  hermetically  sealing  the 
wound  with  a  dressing  impervious  to  water.  Collodion  dressings 
rarely  require  removal  until  the  repair  is  complete. 

2.  Adhesive  plaster  must  be  used  when  the  wound  involves  the 
entire  skin  and  gapes  freely;  it  answers  best  Avhen  bone  underlies 
the  wound,  as  in  wounds  of  the  scalp.  Cut  the  plaster  in  the  direc- 
tion of  the  length  of  the  roll,  and  of  sufficient  length  to  extend  two 
or  three  inches  upon  either  side  of  the  wound ;  compress  the  lips  of 
the  wound  firmly  when  the  strip  is  applied,  as  there  is  always  a  slight 
yielding  of  the  margins,  which  may  amount  to  a  complete  separation; 
the  strips  may  be  parallel  across  the  woimd,  or  so  obli(iue  as  to  cross 
each  other.  When  adhesive  plaster  is  removed,  great  care  is  neces- 
sary^ to  avoid  disturbing  the  apposed  surfaces  ;  raise  each  strip  equally 
from  both  ends  to  the  margin  of  the  wound,  and  turn  it  gently  over 
on  its  axis,  while  extending  each  extremit}'. 

3.  The  interrupted  suture  must  be  a])plied  when  the  wound  is 
of  such  extent  or  so  situated  that  the  adhesive  strip 
does  not  sufficiently  support  its  margins.  Various 
materials  are  used  for  sutures,  as  catgut  and  horse- 
hair, silk  and  hemp,  silver,  iron,  and  lead.  Catgut, 
carbolized,  is  entirely  unirritating,  but  may  be  ab- 
sorbed too  soon;  horse-hair  is  unirritating  and  reli- 
able, but  it  is  not  very  flexible  where  the  knot  is 
foruied  ;  silk  is  irritating,  but  is  generally  preferred, 
the  best  being  that  used  by  dentists,  three-thread  ; 
hemp  resembles  silk,  but  is  not  flexible;  the  best  is 

Fig.  31.  three-pl}^   nianilla,   hardash.^     The   metallic   sutures 

are  unirritating  and  entirely  reliable ;  the  silver  is  more  generally 
used.  If  the  non-metallic  are  used,  needles  of  various  shapes  are  re- 
quired (Fig.  31).  The  needle  with  curved  extremity  (c)  is  more 
generally  used  ;  a  needle  curved  throughout  its  entire  length  (h) 
is  useful  when  the  wound  is  deeply  seated  ;  the  straight  needle 
(«),  with  sharp  point  and  three  cutting  edges,  is  serviceable  in 
1  C.  J.  Cleborne,  U.  S.  N. 


THE  DRESSING. 


47 


Fig.  32. 


Fig.  33. 


wounds  on  a  slightly  elevated  surface;  in  deeply  seated  wounds 
needle  foreeps  are  useful 
(Fig.  32).  If  metallic  su- 
tures are  used,  they  may 
be  inserted  with  the  or- 
dinary suture  needle,  held 
by  forceps.  The  suture- 
])in  conductor  (Fig.  33) 
is  very  useful ;  it  con- 
sists of  a  slightly-curved 

needle  fixed  in   a  handle,  somewhat  enlarged  for  half  an  inch   near 
its  point,  and  perforated  on  the  con- 
cave side. 

Proceed   as   follows:    Pass   the   needle, 
armed   with    the    lij^atiire,    from    without 
inwards  thi-ough  one  lip  of  the  wound,  at 
a  distance  fioni   its  niary;in  varyinj^  from 
a  line  to  one  third  of  an  inch,  according  to 
the  tension  of  the  parts,  at  a  depth  siitfi- 
cient   to   support   the   deep    parts   of    the 
wound,  and  continue   it   through  the  op- 
posite lip  from  witliin  outwards  at  a  point  exactly  corresponding  to  the  inser- 
tion ;  tie  with  the  reef-knot,  and  twist  wire  with  suHicient  firmness 
to   press   the  surfaces  well  together  without   causing   pouting  or 
wrinkling  of  the  lips.   (Fig.  34.) 

The  distance  between  the  sutures  should  not  exceed 
lialf  an  inch,  and  it  is  better,  when  silver  wire  is  used, 
not  to  exceed  one  fourth  of  an  inch.  Between  wide  su- 
tures apply  adhesive  strips. 

4.  The  twisted  suture  (Fig.  34)  must  be  used  when 
the  wound  involves  deeper  tissues  and  the  surfaces  are 
approximated  with  difKculty. 

Pass  a  needle  of  steel,  silver,  or  other  unirritating  metal  I 
sides  of  a  wound,  as  in  the  interrupted 
suture,  and  tlien  twist  the  thread  around 
the  ends  in  the  form  of  a  ligure-of-eight 
(Fig.  35);  when  several  needles  are  re- 
quired they  should  all  he  introduced  he- 
fore  the  thread  is  applied,  which  should  ^^ 
then  also  take  a  diagonal  direction  be- 
tween the  pins  (Fig.  35)  to  protect  the 
intervening  spaces.  t-_^ 

5.  The  quilled  suture  (Fig.  36)  is  to  be  preferred 
when  the  wound  involves  the  perineum;  pass  a  double 
thread  or  wire  as  in  the  interrupted  suture,    but  at 

greater  distances,  and  tie   the  ends  over  (pulls  or  pieces  of  bougie 


^ 


Fig.  35. 


48  OPERATIVE  SURGERY. 

laid  on  the  sides  of  the  wound  ;  fine  interrupted  sutures  should  also 
be  inserted  in  the  intervals  to  sustain  the  lips  in  apposition. 

V.   OPEN  TREATMENT. 

The  open  method  is  adapted  to  those  wounds  which  heal  by  second- 
ary union.  This  process  involves  the  separation  of  the  dead  par- 
ticles and  the  formation  of  granulation  tissue.  From  the  infliction 
of  the  wound  and  the  covering  of  the  surfaces  with  granulations 
there  is  a  constant  liability  to  absorption  of  septic  matters  from  the 
wound  into  the  blooil,  but  when  the  granulations  are  complete  this 
danger  no  longer  exists.^  Though  suppuration  generally  accom- 
panies the  process,  it  is  not  necessary  to  the  organization  and  devel- 
opment of  granulations.  If  the  wound  is  maintained  in  a  condition 
of  perfect  freedom  from  irritating  matters  arising  from  filth  and 
decomposition,  granulations  will  form  and  cast  off  the  stratum  of 
dead  tissues  without  suppuration.^  In  the  treatment  of  an  open 
wound,  therefore,  it  is  important  both  to  preserve  the  surfaces  from 
every  source  of  defilement  from  filth,  and  to  thoroughly  disinfect 
them,  the  air,  and  the  dressings,  so  that  active  septic  ferments  can- 
not gain  access  to  the  wound,  or,  if  present,  will  be  rendered  inert. 
In  dressing  a  granulating  wound,  avoid  breaking  the  granulations; 
for  if  they  bleed,  septic  poisons  may  enter  the  circulation.' 

1.  Incised  wounds  may  be  treated  by  the  open  method,  as  fol- 
lows :  2  Place  the  part  in  an  easy  position,  support  it  by  a  pillow  of 
oakum,  cover  with  gauze,  and  protect  from  the  contact  of  bedclothes 
with  a  cradle;  use  no  sutures  except  at  the  angle  of  the  wound,  nor 
adhesive  plasters,  oiled  silk,  compress,  or  bandage;  wash  the  wound 
at  frequent  intervals  with  earbolized  water  by  means  of  a  douche, 
and  pour  over  it  balsam  of  Peru  ;  receive  the  drainage  in  a  disin- 
fected vessel,  and  remove  it  frequently;  when  suppuration  has  nearly 
subsided  approximate  and  mould  the  flaps  with  adhesive  plaster. 

2.  Contused  wounds  are  made  with  blunt  instruments,  which  so 
lacerate  the  tissues  that  the  dead  particles  pi'event  immediate  union. 
One  of  two  methods  of  treatment  must  be  adopted:  (1.)  When  the 
contusion  is  slight,  convert  the  lacerated  into  an  incised  surface  by 
cutting  away  the  lacerated  tissue  with  a  sharp  knife  and  then  treating 
it  as  an  incised  wound.  (2.)  If  the  contusion  is  severe,  secure  the 
separation  of  dead  matters  by  warm  moist  application  containing 
a  sufficient  quantity  of  carbolic  solution  to  disinfect  sloughs;  union 
will  be  by  granulation. 

3.  Punctured  wounds  made  with  blunt-pointed  instruments  tend 
to  unite  by  granulation.  Cleanse  the  wound  of  all  foreign  matters 
and  disinfect  it  with  carbolic  solution  ;  if  superficial,  a>ttempt  to  se- 

1  J.  Lister.  ^  j.  R.  Wood. 


THE  DRESSING.  49 

cure  union  by  compresses  so  adjusted  as  to  bring  the  surfaces  of  the 
entire  track  in  apposition;  if  the  contusion  is  severe,  denoted  by 
duskiness  of  the  uiarj^ins,  apply  warm  moist  dressinj;s  to  promote 
granulation  ;  if  the  surface  wound  unites  and  pus  forms  det-ply,  the 
external  wound  must  be  reopened. 

VI.  HOT- WATER  TKEATxMENT.i 
This  method  is  adapted  to  wounds  much  lacerated  or  in  <rann;re- 
nous  tissues,  and  lialjle  to  profuse  suppuration;  submersion  of  sueli 
wounds  diiniiiishes  fever,  limits  the  area  of  acute  inflammation,  i-e- 
straius  and  arrests  erysipelas  and  gangrene,  and  prevents  purulent  in- 
filtration, septicaemia,  and  pyiemia;  it  is  not  necessary  to  preserve 
an  al)Solute  uniform  temperature  of  tlie  water,  but  it  should  always 
feel  warm  to  the  patient,  and  this  temperature  is  found  to  be  from 
95°  F.  to  100°  F;  in  cases  of  incipient  or  progressive  gangrene,  the 
temperature  may  be  raised  to  110°  F.  In  case  of  a  recent  wound, 
where  secondary  ha?morrhage  is  at  all  liable  to  occur,  dress  the  liudj 
for  a  few  hours  with  either  warm  or  cold  fomentations,  but  apply 
neither  sutures,  adhesive  plasters,  nor  bandages.  At  the  expiration 
of  this  time  commence  either  the  bath  or  the  warm  water  fomenta- 
tions, and  employ  them  thereafter  systematically;  the  patient  is  at 
liberty  at  any  time  to  lift  the  limb  from  the  bath,  and  he  generally 
does  thi-;  pretty  often,  to  see  how  it  is  progressing.  Warm-wafer  fo- 
mentations are  second  in  value  to  submersion,  in  the  preventing  and 
cure  of  inflammation,  and  are  to  be  reserved  for  those  examples  in 
which  sid^mersion,  for  one  or  another  reason,  cannot  properly  be  em- 
jiloyed.  Fomentations  should  be  employed  after  about  the  tenth  day 
in  all  those  cases  in  which  submersion  is  at  first  practiced;  when  the 
patient  is  weary  of  the  confinement  of  the  bath,  the  limb  is  taken  out 
ami  fomented  during  the  night.  In  using  the  fomentations,  envelop 
the  wound  and  limb  in  several  folds  of  sheet  lint  or  soft  old  mu>lin, 
saturated  with  warm  water,  the  whole  bring  enclosed  in  oiled  silk  or 
vulcanized  rubber;  this  is  to  be  changed  about  once  in  fotir  or  six 
hours.  The  lower  extremities  can  only  be  completelv  and  perma- 
nently submerged  to  a  point  three  or  four  inches  below  tlie  knee,  ami 
the  upper  extremities  to  a  point  a  few  inches  above  the  elbow,  con- 
sequently, submersion  is  limited  to  those  portions  of  the  extremities 
which  are  below  the  f)oints  mentioned.  A  vessel,  in  which  tlie  part 
can  be  immersed,  maybe  obtained  in  any  household;  but  a  more 
covenient  receptacle  is  made  as  follows  :  — 

Construct  an  oblong  zinc  bath,  twenfj'-three  inches  long  by  eight  inches  wide 
and  eight  in  <lepth,  with  somewhat  flaring  margins  where  the  limb  is  to  enter, 
supplied  with  a  movable  cover,  which  leaves  an  opening  for  the  limb,  and  pro- 

1  F.  II.  Hamilton. 
4 


50  OPERATIVE  SURGERY. 

vided  with  a  stop-cock  to  draw  off  and  renevv  the  water;  along  the  upper  and 
outer  margin  of  tlie  bath  are  arranged  small  wire-pins,  upon  which  pieces  of 
cloth  may  be  fastened  for  the  purpose  of  suspending  the  limb;  care  must  be 
taken  not  to  allow  the  limb  to  rest  against  the  edge  of  the  bath,  so  as  to  inter- 
fere with  the  circulation,  and  it  must  be  carefully  adjusted  beside  the  bed,  in 
such  a  position  as  will  be  most  comfortable  to  the  patient. 


CHAPTER   IX. 

THE  APPLIANCES. 

Simplicity  is  not  more  important  in  the  mediate  than  in  the  im- 
mediate dressings  of  wounds.  It  is  better  to  apply  nothing  at  all 
than  too  much,  if  sutures  maintain  parts  accurately  together.^  But 
the  wound  must  be  preserved  in  a  state  of  complete  repose,  and  in 
order  to  secure  that  position  additional  dressings  are  often  required, 
both  to  support  the  first  and  to  maintain  the  parts  in  a  condition  of 
rest.  These  should  be  selected  and  applied  so  as  to  preserve  clean- 
liness, allow  free  circulation  in  the  vessels,  be  easy  of  removal  and 
reapplication,  and  yet  fulfdl  their  special  purposes. 

I.     BANDAGES. 

The  roller  bandage  is  now  employed  almost  exclusively  as  a  reten- 
tive dressing.  Though  simple  in  construction,  and  easy  of  apjtlica- 
tion,  it  has  proved  a  fruitful  source  of  evil  in  the  hands  of  the  inju- 
dicious. The  d.anger  lies  in  undue  compression  of  recently  injured 
or  inflamed  parts,  inducing  mortification,  especially  of  the  extremities; 
cases  have  also  been  litigated  for  alleged  atrophy  and  paralysis  of 
the  limbs  resulting  from  its  use.  The  materials  employed  are 
muslin,  flannel,  linen,  calico,  and  elastic  cloth.  Muslin  is  generally 
selected  of  a  coarse,  unglazed  «piality.  Flannel  is  useful  when  it  is 
desirable  to  secure  warmth.  The  cloth  should  be  cut  or  torn  into 
strips  of  one,  two,  or  three  inches  in  width,  according  to  the  part  to 
which  it  is  to  be  applied. 

1.  The  single  head  roller  (Fig.  37)  consists  of  a  single  piece. 
When  applied  to  a  limb,  especially  for  compression, 
■Tit  should  always  commence  at  the  extremity,  and 
proceed  upwards.    Apply  the  first  turns  most  firmly, 


in  order  to  compress  the  superficial  veins  from  be- 

FiG.  37.  ^ow  upwards;  no  one  turn  should  he  more  firm  than 

those  below.      The  best  general  rule  for  its  apj)li- 

cation  is  as  follows:  It   should  be  done  quickly,  without  pain,  with 

ease,  and  with  elegance.'^ 

1  J.  Croft.  2  Hippocrates. 


THE  APPLIANCES. 


51 


Take  the  cylinder  in  the  palm  of  tiie  rij^iit  liand,  antl  with  the  thiinih  and  fin- 
gers of  the  left  seize  the  free  extremity,  drawiiij^  the  roller  out  six  to  ten  inches 
between  the  thuinh  and  lingers  of  the  right  hand,  the  cylinder  unrolling  in  its 
jialm  ;  place  the  external  surface  upon  the  limb,  and  retaining  it  with  the  firist 
and  second  lingers  of  the  left  hand,  pass  the  cylinder  uuder  the  limb,  and  by 
the  aid  of  the  third  and  fourth  fingers  of  the  left  hand  make  a  turn  or  two 
to  lix  the  initial  cxtreniily  of  the  bandage.  In  continuing  the  apjilication  have 
but  little  of  the  bandage  unrolled,  keep  the  cylinder  close  to  the  limb,  and 
))ass  it  from  one  hand  to  the  other  without  reaching  with  the  respective  bands 
beyond  the  centre  of  the  limb. 

■J.  The  circular  bandage  (Fig.  ■'58)  passes  nearly 
horizontally  around  portions  of  the  limb  of  equal 
diameter,  one  turn  overlapping  the  other  at  fixed 
intervals. 

3.  The  spiral  bandage  (Fig.  .39)  ascends  a  more 
or  less  conical  portion  of  the  limb,  each  succeeding 
turn  ])artially  overlapping  the  other,  with  reverse 
turns  on  the  more  conical  parts,  as  follows  :  — 

At  the  point  where  the  roller  ascends  the  limb  so  rapidly 
as  to  be  irregularly  applied,  press  the  ends  of  the  two  fore- 
fingers of  the  left  hand  upon  the  upper  fourth  of  the  band- 
age, and  retain  it  hrmly  at  that  point;  then  relaxing  the  YiG.  38. 
bandage,  turn  the  cylinder,  held  between  the  fingers  and  thumb,  quickly  and 


Fig.  39. 

completely  over,  by  pronating  the  right  hand,  thus  applying  the  upper  surface 
in  turn  to  the  limb. 

It  is  applied  to  a  finger  as  follows:  Take  a  bandage  an  inch  in  width,  and 
commencing  at  the  wrist  make  a  circular  turn,  leaving  free  two  or  three  inches 
at  the  initial  extremity  (P'ig.  40);  then  cross  the  back  of  the  hand  diagonally  to 
the  root  of  the  finger  to  be  bandaged;  then  along  the  palmar  surface  of  the  dry 


52 


OPERATIVE  SURGERY. 


finger  to  its  tip,  where  the  spiral  commences,  with  or  without  reverses  according 
to  the  shape  of  the  finger;  when  the  finge  •  is  covered  the  bandage  should  pass 
to  the  side  c'  ^ne  wrist  opposite  to  that  where  it  be- 
gan, and  be  tied  to  the  initial  extremity.  If  it  is 
required  to  bandage  other  fingers,  instead  of  tj'ing 
the  two  extremities,  the  bandage  should  pass  around 
the  wrist  and  across  the  back  of  the  hand  to  the  root 
of  the  finger,  and  be  applied  as  above  described. 
In  this  manner  all  the  fingers  may  be  bandaged  with 
a  single  roller. 

4.  The  spica  (Fig.  41)  is  applied  on  the 
upper  part  of  tlie  arm  and  thorax,  of  the 
thigh  and  pelvis,  and  of  the  thumb. 

In  applying  it  to  the  groin  (Fig.  41),  stand  in 
front  of  the  patient,  place  the  initial  extremity  on 
his  right  side,  and  carry  the  cylinder  circular!}' 
around  the  body  twice,  then  carry  i  downwards  and 
around  the  thigh,  passing  from  the  inside  to  the  out- 
side of  the  limb,  then  upwards  around  the  body,  cross- 
ing the  down- 
ward turn  in  the 
groin.  Tiie  first 
iiG.  40.  {m.,^  around  the 

thigh  should  be  as  low  as  its  upper  fourth, 

and  the  subsequent  turns  should  ascend  regu- 
larly until  the  requisite  pressure  is  attained. 
5.  The  Figure-of-eight  bandage 

(Fig.  42)  is  generally  applied  about 

the  joints. 

At  the  knee,  continue  the  bandage  of  the 

leg,  after  it  has  reached  the  lower  border  of 

the   joint,   by  passing  the  cylinder  behind 

the  knee,  obliquely  across  the  ham  to  the  op- 
posite side  of  the 

limb,  around  the  thigh,  and  downwards  again  ob- 
liquely across  the  ham  to  the  point  of  departure ;  each 
successive  turn  should  overlap  the  other  until  the 
knee  is  covered,  or  the  object  attained.  If  the  figure 
of  eight  is  applied  only  to  the  knee  (Fig.  41),  com- 
mence with  two  circular  turns  around  the  leg  just 
below  the  joint,  and  then  carry  the  cylinder  obliquely 
upwards  across  the  ham,  around  the  thigh,  and 
again  downwards  as  before  described. 
6.  The  double-headed  bandage  (Fig.  4.3) 

is  applied  as  follows  :  —    ^ ^ — ^^ 

Take    the   two   cylinders    ^ 1^^! 

in  the  hands,  and,  placing   '■•v,__J  v_^ 

the  outer  surface  of  the  cen-  Fig.  43. 

tral  portion  upon  the  anterior  part,  carry  the  two  cylinders  to  the  back  part  and 

exchange,  then  bring  them  forward  (Fig.  44),  and  reverse,  if  necessary. 


Fig.  41. 


Fig.  42. 


THE  APPLIANCES. 


53 


7.  The  T  bandage  consists  of  the  simple  bandage  with  one  or 
two  pieces  atldiil  at  right  angles  (Fig.  45),  and  is  enij)lojed  in  the 
diseases  of  the  region  of  the  j)erineuMi  and  anus.  Pass  the  horizontal 
portion  around  the  pelvis  and  firndy  secure  the  vertical  strips  be- 
hind, after  being  passed  under  the  perineum  and  the  dressin<Ts. 


"^^^^^ 

^^'~** 

Tt    — — 

CO* 

^——~~~ 

— r-'"^ 

«•»— 

"       — . 

v^ 

— >^    ^ 

\*^— —- — "^ 

"^ 

n:?F;:^ 


Fig.  44. 


Fig.  45. 


8.  The  recurrent  bandage  should  be  five  yards  long  and  two 
inches  wide;  it  is  applied  to  the  head  as  follows:  — 

The  roller  is  first  passed  two  or  tliree  times  around  the  head  in  a  line  running 
just  above  the  eyebrows  and  the  ears,  and  below  the  occipital  protuberance;  next, 
at  tlie  centre  of  the  forehead,  the  cylinder  is  reversed  and  carried  directly  over 
the  liead  to  the  circular  turns  behind,  where  it  is  again  reversed,  and  carried 
back  to  the  forehead,  overla|)ping  the  former  about  one  third,  as  usual;  these 
reverses  to  be  continued  until  first  one  and  then  the  other  side  of  the  head  is 
covered;  and  the  whole  is  completed  by  two  or  three  firm  circular  turns  as  at 
the  commencement;  the  reverses  are  to  be  held  by  the  fingers  of  an  assistant. 


II.    PLASTIC  APPARATUS.i 

This  form  of  appliance  is  required  when  operation-wounds  are  of 
such  nature  and  location  as  to  require  absolute  protection  of  the  part 
from  all  motion.  It  must  be  a|)plicd  with  great  care,  and  with  due 
regard  to  the  liability  to  strangulation  of  parts  recently  submitted  to 
operation.  By  way  of  caution,  it  should  be  stated  that  all  starch, 
chalk,  and  plaster  of  Paris  sjjlints  contract  on  drying,  and  hence  are 
lial)le  to  be  followed  by  harm.-  But  though  unfavorable  results  have 
followed  its  injudicious  use,  this  dressing  is  invaluable  when  prop- 
erly used.^  The  best  safeguard  against  accidents  is  careful  padding 
of  the  limb  and  parts  adjacent  to  the  wound  with  cotton  wool.* 
There  must  be  constant  watchfulness  of  the  toes  or  fintrcrs  involved: 
if  these  parts  become  l)luish,  red,  cold,  or  even  insensii)le,  the  dress- 
ini:  should  at  once  be  removed,  or  if  the  patient  complains  of  severe 
pain  under  the  dressing  it  is  well  to  remove  it.* 

1  S.  B.  St.  John.  2  T.  Bryant.  8  T.  Billroth.  *  Burggraeve. 


54  OPERATIVE  SURGERY. 

1.  The  starch  bandage  is  made  with  starch  or  dextrine  as  fol- 
lows :  — 

Take  common  starch,  a  sufficient  quantity,  and  boil  it  in  water  a  few  minutes. 
Dextrine  is  very  readily  prepared  by  thoroughly  mixing  with  it  spirits  of  cam- 
phor or  brandy,  100  parts  of  the  former  to  GO  of  the  latter,  and  adding  about 
40  parts  of  warm  water.  Envelop  the  limb  with  cotton  wadding,  so  thickly  ap- 
plied as  to  cover  all  the  prominences  and  fill  the  cavities;  over  this  apply  a 
roller  well  saturated  with  the  starch;  along  the  sides  of  the  limb  apply  paste- 
board splints  of  proper  thickness,  soaked  in  hot  water,  and  nicely  shaped  to  the 
limb;  repeat  the  bandage  twice,  and  saturate  the  whole  with  starch,  rubbed  in 
with  the  hands  or  a  brush.  When  the  starch  is  completeh'  Avy,  cut  out  a  piece, 
and  bring  the  edges  together  with  strong  tapes,  or  leather  straps  with  buckles; 
hasten  the  drying,  by  suspending  the  limb,  or  by  applying  hot  bricks  or 
bottles  of  hot  water. 

2.  The  gypsum  splint  is  in  many  respects  preferable  to  starch, 
and  chiefly  owing  to  the  rapidity  of  its  consolidation.  It  may  be  ap- 
plied to  a  part  of  the  circumference  of  a  limb,  or  to  the  entire  limb. 
When  applied  to  a  part  of  the  limb  as  a  splint,  proceed  as  follows:^ — 

First  shave  or  slightly  oil  the  limb;  next  select  a  piece  of  old  coarse  washed 
muslin  of  a  size  so  that  when  folded  about  four  thicknesses  it  is  wide  enough  to 
envelop  more  than  half  of  the  circumference  of  the  limb,  and  long  enough  to 
extend  from  a  little  below  the  under  surface  of  the  knee  to  about  five  inches 
below  the  heel;  select  fine,  well  dried  white  plaster,  and,  before  using,  mix  a 
small  portion  with  water  in  a  spoon  and  allow  it  to  set,  to  ascertain  tlie  length 
of  time  requisite  for  that  process;  if  it  is  over  five  minutes,  dissolve  a  small 
quantity  of  common  salt  in  the  water  before  adding  the  plaster;  the  more  salt  is 
added,  the  sooner  the  plaster  will  set;  if  delay  be  necessary,  the  addition  of  a 
few  drops  of  carpenter's  glue  or  mucilage  will  subserve  that  end;  equal  parts  of 
water  and  plaster  are  the  best  proportions;  sprinkle  the  plaster  in  the  water,  and 
gradually  mix  with  it;  immerse  the  cloth,  unfolded,  in  the  solution  and  saturate 
well:  fold  quickly,  as  before  arranged,  and  lay  it  on  a  flat  surface,  such  as  a  board 
or  a  table,  and  smooth  once  or  twice  with  the  hand  in  order  to  remove  any  irregu- 
larities of  its  surface,  and  then,  with  the  help  of  an  assistant,  apply  it  to  the  pos- 
terior surface  of  the  limb;  turn  np  the  portion  extending  below  the  heel  on  the 
sole  of  the  foot,  and  fold  the  sides  over  the  dorsum,  and  make  a  fold  at  the 
ankle  on  either  side;  apply  a  roller  bandage  pretty  firmly  over  all;  hold  the 
limb  in  a  proper  position,  extension  being  made,  if  necessary',  by  the  surgeon, 
until  the  plaster  becomes  hard;  the  time  required  in  preparing  the  cloth,  mixing 
the  plaster,  and  applying  the  casing  to  the  limb  need  not  be  more  than  fifteen 
minutes. 

When  the  dressing  is  to  enclose  the  limb  completely,  all  the  de- 
tails of  preparation  and  application  must  be  carefully  attended  to  in 
order  to  insure  safety  and  success.  The  following  method  ^  secures  a 
neat  and  serviceable  dressing  :  — 

Select  clean  cotton  batting,  smooth  and  fresh  plaster  of  Paris,  and   the  flimsi- 
est cotton  cloth,  as  crinoline,  which  tear  into  strips  of  two  and  a  half  or  three 
inches  in  width,  make  one  strip  nine  to  twelve  yards  long,  and  the   remainder 
three  yards  long;  lay  the  latter  on  a  kitchen  table  or  board,   and  have  the 
1  J.  L.  Little.  2  D.  w.  Yandell. 


THE  APPLIANCES. 


55 


plaster  well  rul)l)C(l  into  the  cloth;  roll  them  into  cylimiers;  into  an  onlinarv 
wash  basin  one  third  full  of  water  a  little  warm,  put  two  heaping  tablespoon- 
fuls  of  powilered  alum  ;  have  the  whites  of  half  a  dozen  fresh  ef;f;;s  beaten  into 
a  froth;  unfold  the  batting  carefully,  that  it  may  be  in  a  sheet  rather  than  a  roll, 
and  envelop  the  whole  limb,  coverinjjf  well  the  bony  prominences;  secure  the 
cotton  with  the  lon;^  roller,  into  which  no  plaster  has  been  rubbed;  put  the 
plaster  rollers  into  the  basin  of  water;  squeeze  antl  press  them  willi  your  hand 
until  well  wetted;  apply  them  to  the  limb,  one  after  another,  until  the  dressing 
Ls  suHiciently  firm;  three  layers  are  usually  required;  the  rollers  maybe  put 
on  lonj;itu<linally  instead  of  circularly;  make  no  reverse  turns  of  the  band- 
age, as  they  are  unnecessary,  and  give  the  dressing  a  clumsier  appearance 
than  it  otherwise  would  have;  smooth  each  layer  of  bandage  nicely  with  the 
hand,  which  will  add  to  the  firmness  of  the  dressing  and  make  it  dry  more 
quickly;  wait  a  few  moments  for  the  plaster  to  dry;  the  alum  added  to  the 
water  will  greatly  facilitate  this;  when  comparatively  dry  apply  the  whites  of 
the  eggs  over  the  plaster;  then  ajiply  a  roller  without  plaster  over  this;  or  cut 
the  roller  into  strips  and  lay  them  along  the  length  of  the  linjb;  the  egg  pre- 
vents the  plaster  from  chipping;  the  adilitioiial  roller  assists  this,  and  gives  to 
the  dressing  a  finish  which  it  does  not  otherwise  have. 

The  gypsum  may  be  applied  to  the  bandage  by  means  of  an  ap- 
paratus consisting  of  a  tin  pan  with  a  rollef. 

Pass  one  end  of  the  bandage  under  a  rod  and  attach  it  to  a  roller;  put  the 

plaster  on  the  bandage,  turn 
the  roller,  and  as  the  bandage 
passes  under  the  rod  the  phis- 
ter  is  evenly  applied. 

In  removing  tlie  dress- 
ing which  encircles  the 
limb,  it  must  be  cut  down 

„       .  in    the    middle   line   with 

Fig.  46.  ,  •   .    i   i      f 

a  sharp-})0intc(I  kniie  or 

with  shears  made  for  that  purpose  (Fig.  46).^ 

3.  The  silica  bandages  -  are  made  of  the  silicates  of  potash  and 
soda  dissolved  in  an  excess  of  caustic  alkali.  They  form  a  cheap 
and  efficient  fixed  dressing,  which  does  not  contract  in  drying,  and 
is  very  light  and  clean. 

Apply  it  as  follows:  cover  the  part  with  cotton  wool,  lint,  or  a  thin  flannel 
roller,  and  apply  over  this  a  common  dry  bandage;  with  a  brush  or  sponge 
apply  a  coat  of  the  silicate ;  repeat  the  bandage  and  silicate  until  two  or  three 
layers  cover  the  limb;  when  the  last  layer  is  dry,  put  on  another  coat  of  the 
silicate  so  as  to  give  an  even  surface;  expose  the  limb  to  the  air  for  about  half 
an  hour,  when  the  bandage  will  be  firm  enough  to  prevent  movement;  the 
bandage  continues  to  harden  for  about  two  or  three  days.  To  give  greater 
strength  to  the  bandage,  mix  whitening  with  the  silicate  in  sulhcient  quantity 
to  give  the  consistence  of  batter.^  A  rapidly  setting  and  e.xtremely  firm  splmt 
may  also  be  procured  by  covering  the  limb  wiih  cotton-wool,  lint,  wool,  a 
worsted  stocking,  or  any  soft  protecting  material,  and  apply  strips  of  linen, 
bandage,  or  paper  saturated  with  silicate  of  soda  mixed  or  not  with  a  salt  of 
lime,  such  as  chalk,  whitening,  or  phi'iter  of  Paris. 

1  C;.  W.  Wackerhagen.  ■:  W.  W.  Wagstaffe.  3  w.  C.  Elliott. 


56  OPERATIVE  SURGERY. 

CHAPTER   X. 

THE  EEPAIR. 

After  an  operation  an  entirely  new  case  begins,  a  case  not  of 
disease,  but  of  injury.^  Tlie  immediate  effects  of  tbe  operation  are 
seen  in  a  variation  of  temperature;  at  first  it  sinks,  but  not  below 
the  normal;  then  it  ascends,  either  slowly  or  suddenly,  for  a  few 
hours;  in  some  cases  there  are  intercurrent  falls  of  temperature, 
usually  followed  by  renewed  elevations. ^  The  principal  factors  in 
reducing  bodily  heat  immediately  after  operations  are  loss  of  blood, 
the  narcosis  of  the  anajsthetic,  the  pain  of  the  wound,  and  prolonged 
exposure  of  the  body.^  The  intensity  of  this  shock  commonly  deter- 
mines the  time,  and,  in  a  less  degree,  the  intensity  of  the  reaction 
■which  in  the  ordinary  course  immediately  follows ;  in  some  cases, 
even  after  severe  wounds  and  much  depression,  the  reaction  does  not 
go  beyond  the  recovery  of  the  natural  standard  of  the  heart's  action, 
and  of  other  functions  ;  there  are  neither  fever  nor  other  signs  of 
general  disorder,  and  repair  may  make  unhindered  progress.^  In 
every  form  of  wound  a  new  histological  element  is  engrafted  upon 
the  part,  namely,  the  migrating  cells,  and  it  is  upon  the  determina- 
tion of  their  relations  and  changes  that  the  future  condition  of  the 
wound  depends ;  if  they  are  removed  from  the  tissue,  resolution,  or 
a  return  to  the  natural  state,  will  residt;  if  they  undergo  fatty  de- 
generation, pus  will  be  formed;  and  if  they  become  organized,  new 
tissues  will  be  incorporated  with  the  old.*  Repair  nuiy  therefore 
proceed  to  its  termination  with  but  little  more  excitement  than  at- 
tends physiological  processes,  or  complications  may  arise  which 
modify  its  progress  and  its  completion.  When  the  process  is  normal 
tliere  is  an  orderly  series  of  changes,  noticeable  at  every  stage,  and 
when  complications  occur  there  are  marked  and  characteristic  devia- 
tions. 

I.     INDICATIOXS. 

It  is  of  the  first  importance  to  be  able  to  determine  at  all  times  the 
nature  of  the  changes  which  arc  taking  place  in  the  injured  part, 
whether  reparative  or  destructive.  The  most  reliable  indications  of 
these  changes  are  found  in  the  appearance  of  the  wound,  the  degree 
of  bodily  temperature  or  fever,  and  the  nature  of  the  pulse.  When- 
ever there  is  any  considerable  deviation  from  the  normal  healing  of 
the  part,  these  features  of  every  case  are  notably  affected,  sometimes 
so  much  in  advance  as  to  give  the  surgeon  timely  warning  of  ap- 
proaching danger  and  enable  him  to  protect  the  patient  from  serious 

1  Sir  J.  Paget.  2  £.  Wagner.  3  t.  Billroth.  4  e.  Kindtleisch. 


THE  REPAIR.  57 

consequences.  The  state  of  tlie  wound,  the  fever,  and  the  pulse, 
tlierefore,  should  be  accurately  recorded  at  least  twice  daily;  care- 
fully observed,  they  form  a  group  of  most  reliable  indices  of  the 
hourly  proi^ress  of  the  case.  The  j)henoniena  which  I  hey  respect- 
ively present  are  so  interdependent  that  they  must  be  regarded  as 
a  single  series  of  symptoms  having  a  common  cause.  Every  chaii'a' 
should  tberefiin!  be  duly  noted,  and  its  significance  appreciated. 

1.  The  wound  is  the  seat  of  those  local  changes,  rep.Trative  or 
(lestriiclive,  which  occur  in  the  progress  of  repair,  whether  it  j)ursue 
a  normal  or  abnormal  course;  these  changes  are  largely  influenced  by 
the  innnediate  conditions  which  surround  the  wound. 

2.  The  fever,  denoted  by  bodily  temperature,  is,  as  a  ride,  the 
measure  of  blood  heating  by  the  inflammator}-  process,^  and  of  blood- 
])oisoning  by  the  absorption  of  dead  and  septic  matters  into  the  cir- 
culation.^ Any  sudden  increase  of  temp<'rature  always  denotes  some 
important  change  about  to  take  place  in  the  woimd,  and  hence  the 
variations  of  fever  announce  conditions  in  the  reparative  action,  fa- 
vorable or  unfavorable,  many  hours  before  they  are  indicated  by 
local  appearances  or  symptoms.^ 

3.  The  pulse,  though  nnich  influenced  by  mental  states  and  other 
conditions  t'ureiLiii  to  the  wound,  is  still  a  reliable  index  of  the  de- 
gree of  arterial  tension,  or  resistance  of  the  organism  to  the  depres- 
sion and  exhaustion  which  the  irritants  derived  from  the  wound 
induce. 

II.    NORMAL   KEI'.VIK. 

The  process  of  repair  may  proceed  in  a  normal  manner  under  np- 
parently  very  difTerent  conditions,  namely,  in  closed  and  open 
wounds.  In  the  former,  union  may  be  immediate,  or  by  primary 
adhesion,  and  in  the  latter  it  may  by  granulations  or  of  granidations.* 
DifTerent  as  these  [irocessi's  appear  at  first  glance,  the  morphological 
changes  in  the  tissues  are  in  both  cases  the  same.^  Passing  over  the 
familiar  texfural  changes  by  which  union  of  wounds  is  effected,  the 
(juestion  of  greatest  practical  interest  is  as  to  the  conditions  most  fa- 
vorable to  normal  repair  in  these  two  classes  of  wounds,  and  the 
methods  by  which  they  are  secured. 

It  may  be  stated  as  an  accepted  principle  that  the  best  imaginable 
process  of  healing  requires,  as  one  essential  condition,  that  there 
shall  be  an  ab.'ience  of  all  inflammation.*  This  mode  of  repair  is 
truly  physiological,  and  closely  resembles  the  normal  growth  of  tis- 
sues. But  the  repair  is  still  normal  when,  in  certain  wounds,  the 
inflammation  is  limited  in  its  effects.  In  miion  by  adhesion  an  in- 
flanunatory  process  ensues  which  may  be  regarded  as  necessary  for 
the  production  of  new  reparative  material,  but  it  should   not  go  be- 

1  J.  Simon.     2  T.  Biflioth.     8  x.  V.  I'iL-k.     ■«  Sir  J.  Paget.     5  t.  Billrotli. 


58  OPERATIVE  SURGERY. 

yond  tliis,  for  its  continuance  is  a  hindrance  to  that  organization  of 
the  reparative  material  essential  to  complete  adhesion;  so  in  healing 
by  granulation,  if  inflammation  is  present,  and  the  lowest  degree  is 
best,  it  is  only  for  the  production  of  the  first  material  for  granula- 
tion.^ In  general,  the  degree  of  inflammation  will  depend  upon  the 
freedom  of  the  wound  from  the  action  of  putrefactive  matters,  and  the 
presence  and  activity  of  these  agents  will  depend  largely  upon  the 
immediate  care  which  the  wound  receives;  as  in  the  kind  of  dress- 
ings employed,  the  time  and  method  of  their  renewal,  the  protec- 
tion of  the  parts  from  filth,  and  the  prevention  of  collections  of  sep- 
tic ferments.  The  different  methods  of  treatment  variously  affect 
these  results,  and  hence  the  difference  in  the  clinical  history  of 
wounds  according  to  the  kind  of  dressings  applied.  The  daily 
clinical  record  of  wounds  of  equal  average  severity,  treated  by 
these  several  methods,  should  be  thoroughly  understood,  for  the 
choice  of  the  particular  method  in  any  given  case  may  involve  the 
vital  (pit'stiiiu  of  the  results  of  the  operation. 

1.  The  antiseptic  method,'^  when  carrit'd  out  in  all  its  details, 
so  effectually  protects  the  injured  parts  from  the  dangers  of  atmos- 
pheric exposure  that  there  is  far  less  need  of  attending  closely  to 
the  patient's  constitutional  condition.  The  following  is  an  average 
daily  record  of  ordinary  uncomplicated  wounds,  closed  and  open, 
treated  antiseptically,  the  patient  being  a  healthy  adult,  having  a 
normal  pulse  of  82:  — 

1st.  The  closed  wound  is  slightly  swollen  and  red  at  its  margins,  especially 
about  tlie  drain  tube;  the  open  wound  has  a  dull  grayish  appearance;  tempera- 
ture 100' F.,  pulse  92  ;  no  s}'mptoins  of  fever;  dressings  renewed  owing  to  the 
profuse  serous  discharge ;  no  odor. 

2d.  No  change  in  closed  wound  ;  open  wound  is  covered  with  a  thin  creamy 
layer;  temperature  99|'F.,  pulse  88;  appetite  good;  no  symptoms  of  fever; 
dressings  renewed  ;  less  serous  flow;  drain  tube  renewed  ;  no  odor. 

3d.  No  change  in  closed  wound;  open  wound  still  covered  with  a  thin 
white  secretion;  temperature  98^°  F.  to  99J°  F.,  pulse  86;  no  general  symptoms; 
dressings  continued;  no  putrefactive  odor. 

4th.  Closed  woinid  united,  except  where  drain  tube  is  inserted;  open  wound 
shows  granulations,  with  slight  secretion;  temperature  and  pulse  normal;  re- 
move any  sutures  not  required,  and  drain-tube  from  closed  wound  ;  apply 
balsam  Peru  to  open  wound;  no  putrefactive  odor. 

5th  to  10th  da\-s.  No  change  in  s3'mptoms;  dressings  not  renewed.  Wounds 
now  rapidly  consolidate  without  further  change. 

2.  The  ordinary  dressings  ^  give  the  following  daily  record  in  av- 
erage nncomplicated  wcnmds,  closed  and  open,  in  a  healthy  :idult:  — 

1st.  The  margins  of  the  closed  wound  gradually  become  red,  swollen,  hot,  and 
tender,  and  the  surface  of  the  open  wound  has  a  gelatinous,  grayish  appearance, 

1  Sir  J.  Paget.  '-  J.  Lister;  Bellevue  Hosp.  Reports. 

3  T.  Billroth;  Bellevue  Hosp.  Reports. 


THE  REPAIR.  59 

with  yellowish  or  prayish  red  small  particles,  which  are  small  fragments  of  dead 
tissue  still  adherent;  temperature  100^  F.,  pulse  92;  treatment,  cooling  regi 
men;  dressings  unchanged. 

2d.  The  closed  wound  is  more  swollen,  hot,  and  tender,  and  there  is  greater 
strain  on  the  sutures  ;  a  trace  of  reddish-yellow,  thin  tluid  is  seen  over  the 
open  wound;  the  tissues  appear  more  regularly  grayish-red  and  gelatinous, 
aiul  their  boundaries  become  more  indistinct;  temperature  lOP  F.,  pulse  104; 
fliere  is  thirst,  slight  headache,  suppression  of  secretions,  and  restlessness  ;  treat- 
ment, sponging,  laxatives,  cold  drinks;  dressings  renewed  when  soiled  by  dis- 
charges. 

;jd.  The  closed  wound  is  still  more  swollen,  hot,  and  tender,  the  sutures  which 
have  been  most  tense  are  loosened  by  ulceration,  pus  oozes  from  the  deeper 
parts ;  the  secretion  of  the  open  wound  is  [)in-e  yellow,  somewhat  thicker, 
most  of  the  yellow  dead  particles  are  detached  and  flow  off,  and  the  surface  be- 
comes more  even  and  regularly  red,  covered  with  red  nodules,  scarcely  as  large 
as  a  millet  seed,  the  granulations;  temperature  at  its  maximum  rarely  exceeds 
10-1^  F.;  pulse  attains  its  highest  range,  112;  continue  cooling  regimen;  remove 
anj'  sutures  which  have  loosened ;   odor  putrefactive. 

4th.  The  margins  of  the  closed  wound  are  less  swollen,  hot,  and  tender,  and 
the  surfaces  are  united;  pus  flows  from  deep  parts;  the  open  wound  is  well  cov- 
ered with  pus,  but  the  granulations  have  increased  in  size  and  numbers;  tem- 
perature lOP  F.,  pulse  96;  treatment,  nutritious  foods,  and  removal  of  the  re- 
maining sutures,  unless  some  parts  are  still  supported  by  them;  odor  putrefac- 
tive. 

5th  to  10th.  Rapid  suhsidence  of  the  inflammatory  .symptoms  of  both  wounds; 
the  swelling  of  the  closed  wound  decreases;  the  open  wound  becomes  tilled  with 
granulations  to  a  level  with  the  skin;  along  the  margin  the  surface  is  dry,  and 
a  slii^ht  red  line  appears,  followed  by  a  wider  white  band,  the  commencing  cica- 
trization or  formation  of  the  new  epidermis. 

3.  The  hot  ■water  dressing'  is  appliod  to  wotinfls  in  a  con- 
tused, slouch}",  or  ganfri'cnous  condition  ;  before  there  are  visible 
syinjitoms  of  repair  the  (U'ad  tissue.^  must  be  separated;  the  progress 
of  such  wounds  towards  healiu',:  must  at  first  be  slow,  as  the  daily 
clinical  record  proves  of  a  healthy  adult  :  — 

1st.  .The  first  effect  of  the  water  is  agreeable  to  the  patient,  though  pain  is  not 
entirely  relieved;  temperature  100' F.,  pulse  96. 

2d  and  -Sd  days.  The  parts  adjacent  are  swollen,  and  the  integuments  white 
and  sodden  ;  temperature  981^  F.  to  100'  F.,  pulse  88  to  92. 

.5th,  6ih,  7th.  The  parts  are  largely  swollen  from  oedema,  and  the  granulations 
are  covered  with  white  exudation;  temperature  and  pulse  normal. 

7lh  to  10th.  The  wdema  coiUinues,  the  granulations  are  abundant,  and  either 
of  a  fresh,  red  appearance  or  still  covered  with  the  exudation.  At  this  period, 
or  earlier,  according  to  the  indication,  fomentations  should  be  suhstitute<l  for 
submersion.  The  a'llema  subsides,  but  its  (inal  disappearance  is  delaved  some- 
tunes  to  a  period  beyond  cicatrization,  the  cicatrix  being  often  depressed 
thereby  for  months.  In  a  recent  wound,  where  secondary  luvmorrhage  is  liable 
to  occur,  dress  the  limb  for  a  few  hours  with  warm  or  cold  application,  but  with- 
out sutures,  plasters,  or  bandages;  then  resort  to  the  bath  or  fomentations,  as 
directed. 

1  F.  II.  II.\MiLTON;  Bellevue  Hosp.  Reports. 


60  OPERATIVE  SURGERY. 

But  the  course  of  normal  repair  is  liable  to  various  interruptions 
and  complications.  A  wounded  part  appears  to  be  a  structure  in 
which  morbid  conditions  of  the  blood  are  peculiarly  prone  to  manifest 
or  localize  themselves  ;  if  an  exanthem,  as  measles,  appear  after  an 
operation,  the  thickest  of  the  eruption  will  be  at  and  about  the 
wound  ;  the  general  malady  of  erysipelas  may  have  its  local  expres- 
sion chiefly  or  only  at  the  wound,  and  scrofula  or  syphilis,  previously 
latent  in  the  system,  may  find  at  a  wound  a  place  more  fit  for  their 
manifestation  than  any  sound  structure.  ^ 

III.    HEMORRHAGE. 
Repair  may   be   interrupted   at   any   stage  by  hismorrhage  ;    the 
wound  and  tissues  are  thus  filled  with  coagula,  which  separate  the 
flaps,  and,  in  softening,  give  rise  to  pus  and  very  irritating  matters. 

1.  Intermediary  haemorrhage  may  occur  at  any  time  subsequent 
to  reaction,  and  before  suppuration  is  established,  namely,  between 
the  first  and  sixth  days.  It  is  the  result  of  returning  circulation, 
and  if  moderate,  from  small  vessels,  it  demands  no  special  attention, 
for  in  a  few  hours  the  progress  of  inflammation  Avill  prevent  the 
slight  oozings  of  blood;  if  the  bleeding  is  excessive,  or  proceeds 
from  larger  vessels,  it  must  be  promptly  arrested;  if  the  limb  is  in  a 
depending  position,  or  a  bandage  causes  ligation,  change  of  position, 
and  dressings,  cold,  or  pressure  may  answer;  if  these  measures  do 
not  promptly  succeed,  remove  the  dressings,  open  the  wound,  wipe 
away  the  clots,  and  secure  the  vessel  with  a  ligature. ^ 

2.  Secondary  haemorrhage^  occurs  during  the  period  of  suppura- 
tion, or  between  the  sixth  and  twentieth  days,  and  especially  about  the 
fourteenth  day;  it  may  be  sudden  and  severe,  but  more  often  it  is 
slight  at  first.  It  may  be  due  to  many  causes,  the  chief  of  which  are 
sloughing  of  a  contused  artery,  or  of  an  artery  contained  in  a  slough; 
penetration  of  an  artery  by  ulceration;  failure  to  form  a  firm  clot  in 
.its  calibre;  breaking  down  of  the  adhesions  formed  at  the  mouth  of 
the  vessel;  imperfect  closure  of  the  breaches  in  wounded  vessels;  an 
unsealed  end  of  the  distal  portion  of  a  severed  artery;  impoverished 
blood  from  diathetic  disorders,  as  scurvy,  syphilis.  If  the  bleeding 
is  from  a  vein  or  small  arteries,  arrest  it  temporarily  by  pressure 
with  the  finger,  and  permanently  with  a  roller  bandage;  if  the  bleed- 
ing is  from  a  larger  vessel,  apply  a  bandage  evenly  from  the  extrem- 
ity of  the  limb  some  distance  above  the  wound,  with  a  compress  at 
the  wound,  and  a  second  laid  along  the  course  of  the  artery  on  the 
proximal  side;  if  there  is  oozing  from  small  vessels  in  deep  cavities, 
resort  to  haemostatics,  as  persulphate  or  perchloride  of  iron;  if  the 
bleeding  is  parenchymatous,  apply   the   actual  cautery  where  the 

1  Sir  J.  Paget.  2  f.  h.  Hamilton.  3  j.  a.  Lidell. 


THE   REPAIR.  CI 

parts  arc  in  a  sloughing  condition  and  arteries  wil!  not  maintain  the 
liirature,  the  cautery  being  so  thoroughly  applied  as  to  destroy  the 
entire  slough  and  seal  up  the  bleeding  vessels  ;  by  ligature,  if  there 
is  a  wounded  vessel  at  the  seat  of  injury,  tie  bolli  cut  extremities; 
when  compression  has  not  proved  effectual,  ligate  the  trunk  of  the 
arterv;  if  the  limb  or  life  is  seriously  threatened  by  delay  or  the 
use  of  other  uieasures,  resort  to  aMi])iitation  of  the  limb. 

^^.  Parenchymatous  haemorrhage  ^  u.«.ually  occurs  as  an  oozing 
from  the  granulating  or  ulcerating  surface  of  the  wound,  of  blood 
neither  venous  nor  arterial  in  aj)pearance,  but  resembliTig  what  flows 
from  dilated  capillaries;  it  may  also  occur  in  the  primary,  interme- 
diary, and  secondary  periods  in  the  history  of  the  wounds;  in  tlie 
primary  period  it  is  liat)le  to  attend  operation-wounds  made  in  in- 
flamed tissues,  the  capillary  blood-vessels  being  still  paralyzed  by 
the  inflammatory  process,  and  unable  to  contract  and  close  the  open 
vessel;  in  the  intermediary  period  it  occurs  when  the  dilated  capil- 
laries are  so  feebly  and  imperfectly  closed  that  in  the  vascular  excite- 
ment attending  reaction,  the  blood  is  forced  out  of  the  vessels  into 
the  wound;  in  the  secondary  period  it  is  associated  with  pyaemia,  and 
is  caused  by  the  obstruction  of  the  veins  of  the  part  with  coagula.^ 
The  treatment  of  capillary  ha?morrhage  after  an  operation  must  be 
with  the  application  of  a  strong  solution  of  persulphate  or  pcrchloride 
of  iron  directly  to  the  bleeding  surface,  by  laying  on  lint  saturatdl 
with  the  styptic  solution.  If  the  seat  of  hemorrhage  is  a  stump,  the 
dressings  must  be  removed  and  the  wouml  freely  opened.  If  styptics 
are  not  present,  ap|)ly  water  of  the  temperature  of  160°  F.  by  means 
of  a  sponge ;  if  this  fail,  cauterize  with  the  hot  iron.  Haemorrhage 
in  the  secondary  period  from  thrombosis  is  almost  necessarily  fatal, 
owing  to  the  constitutional  condition  of  the  patient,  and  is  to  be  met 
with  styptics  and  pressure,  and,  if  these  fail,  by  ligature  of  the  main 
artery  if  the  patient  is  very  low  with  pya?mia,  or  amputation  if  he 
is  not  too  much  reduced  and  pyajinia  has  not  appeared. 

IV.  GANGRENE. 

When  there  is  complete  loss  of  vitality  of  the  tissues  through  chem- 
ical or  mechanical  action,  death  of  the  parts  follows,  as  in  complete 
arrest  of  the  circulation  by  compression,  or  other  mechanical  cause.* 

1.  Traumatic  gangrene  may  be  one  of  the  earliest  complications 
of  the  wound,  the  margins  rapidly  becoming  cold  and  assuming  a 
shrunken,  dark,  or  piu-plish  apj)earanee,  the  extent  depending  upon 
the  amount  of  tissue  involved.  It  may  be  caused  by  direct  violence, 
the  tissues  being  devitalized,  as  in  crushing  injuries  in  which  the 
amputation  has  been  performed  too  near  the  seat  of  injury;  or  by 
1  J.  A.  Lidell.  2  p.  Stromever.  8  T.  Billroth. 


62  OPERATIVE  SURGERY. 

constriction  or  occlusion  of  the  main  artery  or  vein,  or  of  the  neigh- 
boring vessels  also,  as  after  shot  injuries,  which  either  sever  the 
arteries  or  give  rise  to  large  inflammatory  effusions  that  occlude  the 
collateral  channels;  ^  or,  finally,  by  improperly  applied  dressings 
which  too  much  constrict  the  parts  or  the  vessels.  As  repair 
cannot  proceed  until  the  dead  tissues  are  removed,  the  treatment 
should  aim  to  prevent  extension  of  the  gangrene,  and  secure  an 
early  separation  of  the  dead  structures.  The  first  indication  is  met 
by  removing  every  source  of  irritation,  and  promoting  the  circula- 
tion in  the  part,  and  the  second  by  excision.  AVhere  the  gangrene 
is  limited  to  the  integument,  all  the  dead  tissue  should  be  removed 
with  the  knife  or  scissors,  as  far  as  practicable,  and  the  remainder 
should  be  constantly  disinfected  by  carbolic  solution  to  prevent 
contamination  of  the  wound;  the  process  of  separation  should  be 
hastened  by  moist  and  hot  applications,  as  poultices.  If  the  gan- 
grene involve  the  limb,  as  after  ligature  of  the  artery,  gun-shot,  or 
tight  bandaging,  amputation,  promptly  performed,  is  the  sole  remedy, 
the  point  at  which  it  should  be  practiced  depending  upon  the  place 
of  vascular  injury.^ 

2.  Phagedcena  -  may  occur  as  a  round  black  slough,  with  thick- 
ened border,  or  in  the  spreading  form  in  which  the  wound  opens 
with  an  irregular  edge,  and  a  foul,  sloughy  surface;  its  origin  is  ob- 
scure, and  though  possibly  due  to  carelessness  in  the  use  of  mate- 
rials in  dressing  wounds,  hospital  influences  have  not  been  proved  to 
orif^inate  it,  as  in  the  case  of  hospital  gangrene;  little  or  no  constitu- 
tional fever  accompanies  it,  and  it  involves  very  little  danger  to  life; 
in  some  cases  the  pain  in  the  wound  is  very  great,  requiring  lai'ge 
opiates,  and  again  the  sloughing  spreads  with  but  little  pain;  occa- 
sionally the  pain  ceases,  and  the  temperature  due  to  the  traumatic 
fever  falls  to  98=^.  twenty-four  hours  before  the  slough  appears. 
The  treatment  consists  in  securing  a  healthy  surface  of  the  Avound 
by  the  use  of  strong  caustics,  as  nitric  acid,  while  the  patient  is 
un'de'r  an  anaesthetic,  and  such  general  treatment  with  cathartics, 
anodynes,  and  tonics  as  the  case  may  require. 

3.  Hospital  gangrene  appears  as  a  pulpous  or  ulcerous  change  in 
the  granulations  of  a  wound,  of  a  yellowish-gray  color,  and  extends 
to  the  surrounding  skin.^  It  is  a  contagious  disease,  and  occurs  in 
the  wards  of  hospitals,  overcrowded  and  badly  ventilated  and 
cleansed;  it  may  attack  any  wound,  at  any  stage  of  repair,  as  the 
result  of  inoculation,  or  may  be  generated  where  to  all  appearances 
there  is  no  abrasion  of  even  the  cuticle;  its  first  appearance  in  an 
open  wound  is  marked  by  blackish-gray  points,  and  suspension  of 
the  healthy  secretion,  the  discharge  becoming  thin  and  sanious;  the 

1  J.  A.  Lidell.  ^  T.  Holmes.  ^  t.  Billroth. 


THE  REPAIR.  G3 

edges  are  livid,  raisiMl,  and  everted,  while  a  broad  erysipelatous  area 
extends  in  the  .-kin,  and  the  whole  part  exhales  an  offensive  and 
jienetrating  odor;  in  ^ix  to  twenty-four  hours  the  <:rayish  spots  mul- 
tiply and  eoinpletely  cover  the  part  with  a  I)idpy,  tenacious  mass, 
through  which  ichorous  Huid  is  discharged,  the  slou^ih  burrowin" 
under  the  integuments,  particularly  in  the  direction  of  the  cellular 
planes;  circular  sloughs  separate,  but  not  deeplv,  giving  a  rafrtred 
appearance  to  the  wound;  the  general  symptoms  arc  jjain  in  the  part, 
often  excruciating;  fever  is  not  uniform;  when  present  is  typhoid. ^ 
In  the  treatment,  the  patient  should  be  isolated,  in  a  well-aired 
room,  and  have  nutritious  diet;  opium  should  be  given  to  allav  pain, 
and  tonics,  (piinine  and  iron,  to  improve  the  general  condition.  The 
local  treatment,  which  is  of  the  greatest  importance,  should  be  first 
directed  to  thorouudi  cleansing  and  disinfection  of  the  wound,  and 
for  this  purpose  bromine  -  gives  the  best  results:  cleanse  the  affected 
part  of  all  secretions,  by  washing  with  soaped  water,  remove  with  for- 
ceps and  scissors  all  sloughy  tissue,  free  the  surface  of  all  moisture 
by  swabbing  with  lint  and  penetrating  every  recess,  apply  the  pure 
bromine  to  the  open  wound  by  means  of  a  glass  pipette,  and  to  the 
recesses  by  means  of  lint  dipped  in  the  bromine  and  forced  into  cav- 
ities; paint  the  surrounding  tissues  with  a  solution  of  bromine  3i  to 
water  3ii;  apply  a  poultice  to  relieve  pain  and  promote  separa- 
tion of  the  slough. 

Otiicr  useful  remedies  are  permanganate  of  potassa,^  a  concentrated  solution 
applied  with  a  hair  pencil,  and  lint  saturated  with  the  solution,  to  be  repeated 
every  three  or  four  hours;  spirits  of  turpentine  ■•  applied  thorouj^hly  every  three 
or  four  hours;  persulphate  of  iron;  concentrated  solution  of  carbolic  acid. 

V.     IXILAMMATIONS. 

Those  forms  of  inflammation  which,  by  their  destructive  local  ef- 
fects, seriously  interfere  with  rejiair,  di-pend  upon  septic  j)rocesses 
in  the  wound;  the  degree  of  development  of  these  inflammations,  or 
wiiether  they  are  developed  at  all.  depends  upon  the  nature  of  the 
wound,  the  mode  of  dressing,  the  stat6  of  the  atmosphere  in  which 
the  patient  is,  the  mechanical  factors  which  favor  the  entrance  of 
putrid  substances  into  the  tissues  and  the  blood,  and  the  rpiality  of 
such  putrid  sulistan<'es.^ 

1.  Erythema  appears  as  a  blush  around  the  wound,  without  fever 
or  other  symptom;  there  is  slight  tumefaction  from  turgescence  of 
the  capillaries,  and  the  migration  of  leucocytes  into  the  cutis  and 
subcutaneous  areolar  tissue.^  It  is  due  to  the  action  of  irritants  upon 
the  specially  sensitive  papillary  body,  which  reacts  to  the  stiiuulus  by 

1  F.  H.  Hamilton,  Jr.;  J.  Jones.  2  M.  Goldsmith.  »  Hinkley. 

*  Hachenberg.        5  £.  Wagner.        ^  R.  Volkman. 


64  OPERATIVE  SURGERY. 

hyper«niia.i     It  may  terminate  in  resolution  or  inflammation.     The 
treatment  indicated  is  cleanliness  and  cold. 

2.  Erysipelas  has  a  toxic  origin;  the  wound  may  be  poisoned  at 
the  time  of  the  operation  and  erysipelas  follow  wiihin  a  few  hours,  or 
blood  mixed  with  decomposing  secretions  may  excite  the  disease  on 
the  second  or  third  day;  or  the  poison  may  reach  the  wound  through 
the  air,  sponges,  and  dressings  at  any  time;  the  inflammation  is  gen- 
erally limited  to  the  cutis,  and  spreads  through  the  lymphatic  net- 
work.2  Organisms,  as  bacteria,  are  found  in  the  vessels  of  the  in- 
flamed skin,  the  number  varying  with  the  progress  and  severity  of 
the  disease, 3  but  their  relation  to  its  origin  is  undetermined.  The 
attack  is  often  ushered  in  by  a  chill,  followed  by  a  fever;  the  edges 
of  the  wound  become  red  and  swollen,  and  this  area  extends  with 
burning,  stinging  pains;  the  temperature  rapidly  rises  to  104°  F.  or 
106^  F.,  and  fluctuates  but  slightly  until  the  inflammation  subsides; 
the  disease  continues  a  variable  time,  but  rarely  exceeds  ten  days. 
The  indications  are  to  cleanse  and  disinfect  the  wound  and  adjacent 
parts  with  carbolized  water,  1  to  20;  inject  a  stronger  solution,  1  to 
10,  when  practicable,  into  the  inflamed  connective  tissue;  apply 
cloths  wet  with  a  weaker  solution,  1  to  60,  to  the  external  surface; 
secure  perfect  drainage  of  the  wound;  correct  any  existing  derange- 
ments of  the  digestive  organs;  administer  tr.  ferri  muriat.  in  full 
doses,  and  add  quinine,  stimulants,  and  nutritious  food,  as  the  case 
may  require. 

3.  Lymphangitis  may  occur  in  any  wound,  and  is  due  to  a  poison 
passing  through  the  lymphatic  vessels;  this  poison  may  be  decom- 
posed secretions  from  the  wound,  or  putrid  matters;  it  appears  as  fine 
red  striae,  running  longitudinally  from  the  wound  towards  the  swollen 
and  sensitive  glands;  the  limb  is  painful  on  motion;  there  is  fever, 
lo?s  of  appeti'e,  and  general  depression;  the  inflammation  may  ter- 
minate in  resolution,  or  in  the  formation  of  abscess  at  some  point. '■^ 
The  treatment  should  be  to  cleanse  the  wound  of  all  irritating 
matters,  and  elevate  the  inflamed  part.*  If  there  is  gastric  derange- 
ment, give  an  active  purgative,  make  application  of  soothing  lotions 
to  the  inflamed  vessels,  and  poultices  to  the  glands;  nitrate  of  silver 
applied  to  the  track  of  the  vessels,  and  inunctions  of  mercurial  oint- 
ment, are  often  useful,  but  the  latter  may  induce  salivation  ;  ^  wad- 
ding or  moist  warmth,  applied  to  the  limb,  to  maintain  an  elevated 
regular  temperature  is  important ;  ^  if  the  inflammation  becomes  dif- 
fused, abscesses  will  form,  which  must  be  early  opened. 

4.  Septic  inflammation  arises  from  putrid  matters  on  wounds 
which  diffuse  rapidly  in  the  meshes  of  the  cellular  tissues,  and  cause, 

1  E.  Rindfleisch.  -  T.  Billroth.  3  Lukomsky ;  W.  Moxon. 

4  T.  Brvaiit.  ^  T.  Holmes. 


THE  REPAIR.  65 

on  the  second,  third,  or  fourth  day,  those  forms  of  inflammation 
characterized  by  rapid  extension  and  decomposition  of  the  inflamma- 
tory pro(hict;  subse(juently,  when  there  is  already  sui)puration,  and 
the  wound  is  o[)en,  mechanical  irritation,  foreign  bodies,  or  infection 
of  the  wound  may  induce  phlegmonous  suppuration  around  the 
wound.  ^  The  treatment  should  be  the  removal  of  every  source  of 
irritation,  thorough  cleansing  of  the  wound,  and  disinfection  of  the 
entire  area  of  intlannnatory  excitement  with  strong  carbolic  solutions. 

5.  Acute  inflammation  '  may  appear  at  any  stage  of  the  healinf, 
but  unless  excited  by  local  irritation,  its  occurrence  becomes  less 
probable  as  the  time  increases;  it  is  most  liable  to  attack  wounds  of 
those  tissues  in  which,  from  ordinary  causes  or  as  if  spontaneously, 
infiamnuition  is  most  frequent,  namely,  the  joints  and  the  serous 
membranes.  It  may  be  of  a  sthenic  or  asthenic  type ;  the  former 
being  attended  with  more  swelling,  pain,  and  redness,  and  a  higher 
gi-ade  of  fever;  but  the  effects  on  the  healing  process  are  the  same, 
namely,  suspension  of  repair,  and  degeneration  of  the  new-formed 
structures;  granulations  become  cedematous  or  shrunken,  thin  serous 
discharge  takes  the  place  of  pus,  and  new  cuticle  is  cast  off.  The 
treatment  of  sthenic  inflammation,  when  perilous  to  the  part  or  to 
life,  should  be  actively  antiphlogistic,  namely,  bleeding,  local  or  gen- 
eral, according  to  the  condition  of  the  patient  and  the  seat  of  the 
wound;  moist,  soft  ajiplicutions  to  the  ])art,  with  ice  or  cold  irriga- 
tion; in  the  asthenic  form,  the  ri'inedies  must  be  of  an  opposite  kind, 
namely,  wine  and  tonics  internally,  and  warm  poultices  to  maintain 
the  heat  of  the  part,  with  fiee  use  of  disinfectant  solutions. 

6.  Chronic  inflammation  ^  not  unfrequently  occurs  in  healing 
wounds,  especially  amj)utation  and  excision  wounds,  and  is  chiefly 
a  local  fault;  the  granulations  become  pale,  firm,  cedematous,  the 
adjacent  structures  feel  lumpy,  heavy,  firm,  and  consolidated,  as  if 
filled  with  half-organized  matter;  it  destroys  the  natural  mobility  of 
parts,  and  is  associated  with  tardy  and  insecure  healing;  if  the  heal- 
ing is  not  far  advanced,  it  may  be  dangerous  through  the  usually 
coincident  softening  and  degeneration  of  tlie  proper  textures  of  the 
part  and  of  the  arteries.  The  treatment  is  local  stimulants,  friction, 
and  pressure ;  the  ceratum  hydrargyri  compositum  is  a  useful  appli- 
cation. 

VI.  FE^Ti:RS. 
Though  the  fevers  which  complicate  operation-wounds  have  their 
origin  in  local  changes,  their  destructive  effects  appear  chiefly  in  the 
systemic  circulation.  Frequently  as  fever  is  met  with,  it  is  not  an 
essential  accompaniment  of  wounds  as  such,  but  is  always  an  acci- 
dental affection;  it  may  be  developed  at  any  time  from  the  reception 

1  Sir  J.  Paget. 


66  OPERATIVE  SURGERY. 

of  the  injury  to  tlie  healing  of  the  wound. ^  Its  presence  must  there- 
fore be  regarded  as  a  complication  indicating  changes  other  than 
tho?e  which  are  required  in  the  simple  act  of  healing.  As  a  rule,  in 
those  cases  in  which  fever  appears,  it  begins  on  the  second  day  and 
continues  until  the  seventh;  if  an  operated  pati'  nt  is  free  from  fever 
at  the  expiration  of  the  fourth  day,  he  will  probably  remain  without 
fever.  1  As  the  etiology  of  tliese  fevers  is  not  well  understood,  the 
terms  used  to  designate  them  are  vague  and  unsatisfactory;  but  as 
they  are  familiar  it  is  desirable  to  employ  them,  with  such  restricted 
and  well-defined  meaning  as  will  give  them  the  greatest  practical 
significance.  The  following  classification  of  the  so-called  fevers 
which  may  occur  after  operation  wounds  is  more  nearly  in  accord- 
ance with  the  present  accepted  views  of  their  causes  and  pathology. 

1.  Traumatic  fever,  which  ordinarily  includes  the  febrile  affec- 
tions following  injuries  and  operations,^  may  be  limited  to  that  in- 
crease of  bodily  temperature  due  to  the  immediate  effects  of  the 
operation,  or  traumatism.  The  shock  of  the  ojieration  is  often  fol- 
lowed by  excessive  reaction,  Avith  elevation  of  temperature  not  unlike 
inflammatory  fever.  The  pulse  and  respiration  become  more  rapid, 
the  former  in  a  greater  ratio  than  the  latter,  particularly  when  there 
has  been  much  loss  of  blood;  the  pulse  is  also  generally  fuller  and 
harder;  the  skin  is  flushed  and  feels  hot;  thirst  is  increased  and  ap- 
petite lessened;  the  water  of  the  urine  is  diminished;  the  bowels 
are  inactive;  the  tongue  usually  Avhite-coated,  large,  and  moist;  the 
sleep  short  and  often  disturbed  ;  the  elevation  is  variable,  and  bears 
no  definite  proportion  to  the  severity  of  the  injury,  or,  so  far  as  is 
yet  known,  to  any  of  the  events  connected  with  it;  not  rarely  it  sub- 
sides within  twenty-four  hours. ^  The  treatment  should  be  pre- 
ventive, by  guarding  against  its  causes,  namely,  loss  of  blood,  nar- 
cosis, exposure  to  cold  and  shock. 

2.  Inflammatory  fever*  appears  with  those  changes  in  the  wound 
recognized  as  peculiar  to  inflammation,  and  results  from  the  local 
production  of  heat  through  textural  changes  by  which  tlie  tempera- 
ture of  the  entire  mass  of  blood  is  gradually  elevated.  The  absorp- 
tion of  particles  of  dead  tissue  may,  even  at  this  early  period,  be  one 
element  in  causing  a  rise  of  bodily  heat.^  The  presence,  intensity, 
and  duration  of  this  fever  depend  upon  the  presence,  intensity, 
and  duration  of  the  inflammatoty  process;  it  may,  therefore,  be  ab- 
sent, or  slight,  or  severe.  When  present,  the  patient  feels  hot,  or 
alternately  hot  and  chilly;  his  skin,  lips,  and  mouth  become  dry; 
the  urine  is  less  and  less  in  quantity,  and  of  higher  color;  the  pulse 
is  quickened,  tongue  dry  and   furred;  there  is  thirst,  restlessness, 

lintolerance  of  disturbance,  face  flushed  and  anxious,  troubled  sleep, 
1  E.  AVagner.  2  T.  Billroth.  3  Sir  J.  Paget.  *  J.  Simon. 


THE  RKPAIR.  67 

or  drlirinin.  It  lasts  from  one  to  seven  days,  the  lnL;liest  tempera- 
ture heiiij;  readied  upon  the  first  or  seeond  day,  and  seldom  from 
the  third  to  the  fifth  days.i  Relieve  the  wound  of  tension  by  re- 
moving dres?inj,fs,  sutures,  or  collections  of  fluid  which  cause  undue 
irritation;  cleanse  the  wound  with  carholized  solutions,  1  to  40;  make 
cold  applications  to  the  part,  if  tliey  aie  tolerated;  give  cooling 
drinks;  use  spongini;  with  culd  water,  and  aconite  to  depress  the 
heart's  action. 

3.  Septic  fever,  s(|)tic;emia,  is  a  constitutional,  generally  acute 
disease,  due  to  the  absorption  of  various  putrid  substances  into  the 
blood, 2  such  as  the  putrid  and  toxic  products  of  decomposing  pus 
and  blood,  and  the  exudative  detritus  of  gangrejious  marrow.8  Deep 
wounds,  and  those  involving  bone,  in  the  course  of  which  decomposi- 
tion of  the  extravasated  blood,  stagnant  pus,  and  gangrenous  tissues 
occur,  are  the  more  frequent  sources  of  the  poison  of  septica?mia.i 
These  fluids  are  highly  charged  with  organic  germs,  bacteria,  which 
seem  to  have  a  causative  relation  to  their  destructive  effects.  The 
chief  factors  in  the  production  of  the  putrescent  fluids  of  wounds  are 
(1)  the  formation  upon  the  wound  of  putrid  substances,  or  septic 
poisons;  (2)  debilitating  influences,  as  fatigue,  loss  of  sleep,  alcoholic 
habits,  exposure  to  cold  prolonged  several  hours  after  injury;  (3)  at- 
mospheric agencies  created  by  the  crowding  of  the  sick,  or  the  pres- 
ence of  putrid  emanations.*  The  poisons,  or  miasma,  which  vitiate 
the  air  must  be  regarded  as  the  dust-like  diied  constituents  of  pus, 
and  possibly  also  accompanying  minute,  living,  and  active  organisms, 
which  are  suspended  in  the  air  of  badly-ventilated  sick-rooms,  where 
patients  are  carelessly  attended  and  there  is  deficient  cleanliness.-' 
These  causes  may  act  singly  or  together,  but  as  soon  as  the  blood 
has  become  altered  by  its  infection,  and  the  fever  has  declared  itself, 
the  suppuration,  instead  of  remaining  local,  becomes  generalized.^ 
The  pathological  changes  are  not  characteristic,  and  no  metastatic 
abscesses  are  present.^  Septic  fever  usually  appears  two  to  four 
days  after  the  injury;  the  wound  often  does  not  suppurate,  but  dis- 
charges a  thin,  bloody  secretion,  occasionally  containing  air-bubbles; 
in  its  vicinity  very  extensive  inflammatory  oedema  occasionally  de- 
velops within  a  few  hours  or  days;  the  skin  is  of  a  peculiar  red- 
dish-brown color;  the  constitutional  di-ease  generally  begins  quickly, 
usually  without  chills.^  Its  grade  will  depend  upon  the  quantity 
and  quality  of  the  absorbed  fluids ;  it  may  have  the  severity 
only  of  a  febricula,  scarcely  recognizable  from  the  ordinary  in- 
flammatory fever  of  wounds,  or  it  may  have  a  distinct  onset,  with 
well-marked  stages  throughout;  or,  finally,  it  may  overwhelm  the 
patient  suddenly,  like  the  severest  diseases  from  blood-poisoning. 
1  E.  Wagner.  2  x.  Billrotli.  8  L.  Gosselia. 


68  OPERATIVE  SURGERY. 

The  symptoms^  develop  as  follows:  patients  are  apathetic  or  sleepy, 
if  not  comatose;  occasionally  there  is  excitement,  and  even  maniacal 
delirium;  the  fever  at  first  rises  high,  but  later  the  temperature  falls 
to  the  normal  or  even  below  it;  chills  are  very  rare  at  first,  and 
never  occur  in  the  course  of  the  disease  ;  the  tongue  is  dry,  often 
hard,  interfering  with  speech;  there  is  thirst,  but  patients  are  too 
apathetic  to  drink;  there  n)ay  be  profuse  diarrhoea,  rarely  vomiting; 
at  first  there  may  be  great  sweating,  but  later  the  skin  is  dry  and 
flabby;  the  urine  is  scanty,  concentrated,  and  occasionally  albumi- 
nous; urine  and  faeces  are  finally  passed  in  bed;  usually  the  patient 
dies  in  perfect  coUap^^e,  with  a  thread-like  and  very  frequent  pulse. 
In  the  treatment,  three  indications  are  prominent:  (1)  removal  from 
the  wound  of  all  septic  matters,  that  no  more  may  enter  the  circula- 
tion; accumulating  fluids  must  be  drained  off,  every  cause  of  irrita- 
tion removed,  and  thorough  disinfection  of  all  parts  of  the  interior 
with  bromine,  or  a  solution  of  carbolic  acid,  frequently  practiced; 
(2)  support  of  the  vital  powers  until  the  absorbed  poison  is  eliminated; 
nourishing  food,  stimulants,  quinine  and  iron,  liberally,  are  the  most 
useful;  (3)  change  of  the  patient's  location  to  secure  better  sur- 
roundings; if  the  weather  permit,  remove  him  to  the  lawn,  or  bal- 
cony, but  if  this  is  not  practicable,  change  his  room  for  one  having 
abundance  of  fresh  air  and  sunlight.^ 

4.  Pyaemic  fever,  pyjcmia,  in  its  restricted  meaning,  has  its 
source  in  venous  thromboses  which  do  not  organize,  but  under- 
go a  simple  and  more  frequently  putrescent  softening,  caused  or  at 
least  favored  by  ichorous  suppuration  around  the  vein;  emboli,  pro- 
duced from  such  thrombi,  go  from  the  right  heart  into  the  lungs, 
and  become  impacted  in  medium-sized  and  small  arteries,  or  even 
capillaries,  and  cause  metastatic  abscesses,  owing  to  their  putrescent 
nature;  they  may  reach  the  kidneys,  spleen,  liver,  and  other  vascu- 
lar organs.^  The  symptoms  usually  set  in  suddenly,  with  a  severe 
chill  lasting  several  minutes  to  an  hour;  the  temperature  rises  from 
102°  F.  to  105°  F.  in  a  few  hours;  the  chills  recur  during  the  first 
days,  usually  daily,  rarely  regularly,  at  times  even  several  chills  a 
day;  less  frequently  they  are  entirely  absent;  the  chill  is  followed 
by  intense  heat,  and  then  profuse  perspiration  sets  in;  the  skin  may 
be  dry  or  damp,  occasionally  is  covered  with  sudamina,  later  be- 
comes more  or  less  icteric ;  there  is  loss  of  appetite,  great  thirst, 
thickly  coated  and  frequently  dry  tongue,  and  often  painless  diar- 
rhoea; the  face  is  haggard;  there  is  general  bodily  and  mental  de- 
pression, and  frequently  headache  ;  the  organs  affected  with  metas- 
tatic inflammation  exhibit  only  moderate  symptoms,  and  they  are 
most  marked  when  the  respiratory  organs  and  joints  are  affected  ;  in 
1  T.  Billroth.  2  L.  Gosselin.  3  £.  Wagner. 


rilE  REPAIR.  69 

the  recent  wound  there  is  raj)i(l  (kcay  of  the  injured  tissues  and  in- 
tense inHauiniation  of  the  surrounding'  parts,  while  in  tlie  granulatin" 
wound  the  secretion  usually  diminishes,  pus  becomes  thinner,  ichor- 
ous; or  the  wound  bleeds,  is  painful,  and  granulations  bicome  smaller 
and  flal)by;  the  surrounding  parts  are  a-deniatous,  the  veins  and 
lymphatics  give  signs  of  thrombosis  and  inflammation,  and  the  entire 
limb  occasionally  appears  remarkably  withered;  death  usually  occurs 
after  an  acute  course,  lasting  one  or  two  weeks,  more  rarclv  a  sub- 
acute, and  still  more  rarely  a  chronic  course,  in  which  the  cldlls  de- 
crease in  number  and  intensity;  recovery  is  extremely  rare. ^  The 
treatment  should  be  pure  air,  cleanliness  and  disinfection,  nutri- 
tion and  stimulants.  The  ])atient  must  be  removed  to  the  open 
air  and  sunlight,  if  practicable;  the  wound  must  be  disinfected  with 
carbolized  solutions,  and  kept  perfectly  clean,  and  the  most  nutritive 
and  easily  assimilable  foods,  as  milk,  beef-juice,  should  be  given, 
with  stiiimlants,  and  quinine  and  iron  as  tonics  should  be  adminis- 
tered in  as  liberal  quantities  as  can  be  borne.  Amputation  and  dis- 
articulation in  acute  septicaemia  and  pyjemia  rarely  have  a  perma- 
nently beneficial  effect,  but  when  these  affections  become  chronic 
amputation  may  save  life.^ 

5.  Hectic  fever  is  a  continued  fever,  remittent,  having  great  dif- 
ferences in  the  morning  and  evening  temperature  of  the  body,  and  is 
due  to  the  constant  absorption  of  the  products  of  inflammation,  es- 
pecially of  disintegration  ;  it  is  most  frKjuent  and  most  intense  from 
rapid  breaking  down  of  the  inner  wall  of  large  abscesses,  and  pro- 
gressive ulceration.-  It  is  always  preceded  by  indisposition,  and 
may  begin  suddenly  with  severe  rigors,  though  generally  it  creeps  on 
gradually  and  stealthily;  the  exacerbation  is  usualh-  in  the  after- 
noon, lasts  six  to  nine  hours,  then  gradually  passes  off  to  reappear 
about  the  same  time  the  next  day;  there  may  be  two  paroxysms  in 
twenty-four  hours;  the  chill  may  be  long  and  severe,  the  patient  oc- 
casionally shivering  for  hours,  or  the  sensation  of  cold  may  be  very 
slight  and  its  duration  variable  ;  the  chilliness  is  followed  by  reac- 
tion, usually  violint  in  proportion  to  the  pievious  depression,  grad- 
ually merging  into  a  profuse  sweat,  wiih  tranquil  and  refreshing 
sleep ;  in  the  interval  the  pulse  continues  frequent  and  easily  ex- 
cited;  the  face  is  pale,  shrunken,  and  careworn  ;  emaciation  begins 
early,  and  is  progres>ive  ;  the  tongue  is  generally  clean,  often  red  at 
the  tip  and  edges,  or  smooth  and  glossy  ;  the  appetite  is  good,  often 
voracious,  and  though  digestion  continues,  assimilation  fails;  there 
is  coldness  of  the  limbs,  but  the  hands  and  feet  are  dry,  hot,  and 
burning;  as  the  disease  progresses,  emaciation  increases,  the  pulse 
daily  loses  power,  sweating  is  more  profuse;  bowels  often  loose; 
1  E.  W'agiiur.  2  j.  UiUroth. 


70  OPERATIVE  SURGERY. 

evening  exacerbation,  with  chilliness,  is  more  severe,  and  morn- 
ing remission  more  max'ked  ;  still  later,  all  the  symptoms  are  ag- 
gravated, the  appetite  begins  to  fail,  aphthous  spots  occur  on  the 
tono-ue,  oedema  appears  about  the  ankles  and  feet,  chills  and  sweats 
which  are  colliquative  succeed  each  other  at  shorter  intervals,  emaci- 
ation reaches  an  extreme  degree,  bed  sores  foini,  the  mind  continues 
clear  until  near  the  close,  Avhen  unconsciousness  supervenes.^  The 
first  requisite  =n  treatment  is  to  relieve  the  system  of  the  exciting 
cause,  as  by  uisinfecting  and  destroying  the  internal  surface  of 
open  abscesses;  or  by  their  removal  with  the  knife,  as  the  exsec- 
tion  of  a  carious  joint,  or  the  amputation  of  a  limb  affected  with  an 
incurable  source  of  suppuration  ;  the  second  indication  is  to  sustain 
the  patient  with  tonics,  as  quinine  and  suli)h.  acid,  given  in  antici- 
pation of  the  evening  exacerbation,  muriated  tincture  of  iron,  or 
other  form,  with  wine,  brandy,  wine  whey,  ale,  or  porter;  give  easily 
di(»-ested  and  assimilated  foods,  as  milk,  eggs,  meat-juice  ;  finally, 
secure  fresh  air  and  perfect  cleanliness.^ 

VII.  NERVOUS   AFFECTIONS. 
Affections    of   the   nerves    and   of    the   nervous   system  following 
■wounds  are  frequently  troublesome   and   even  dangerous  complica- 
tions of  operation  Avounds. 

1.  Pain,^  other  than  that  which  is  excited  by  inflammation,  foreign 
bodies,  improper  dressings,  and  wrong  posture,  may  complicate 
wounds.  It  may  appear  (1)  only  as  an  exaggeration  of  the  ordinary 
pain  of  wounds,  severe  and  abiding  long,  through  personal  sensi- 
bility and  so-called  nervousness,  and  is  usually  continuous  with  the 
immediate  pain  of  the  wound,  or  commences  not  more  than  an  hour 
or  two  after  it;  (2)  in  some  cases  a  wound  is  the  beginning  of  a  long- 
continuing  neuralgia  in  or  near  the  injured  part;  or  (3)  it  is  due 
to  partial  division  of  a  nerve,  or  (4)  the  confinement  of  effusions 
under  dense  fasciae.  For  the  first  form,  hypodermic  injection  of 
morphia,  or  ice  bladders,  or  opium,  in  full  doses,  are  proper  rem- 
edies; the  second  generally  resists  all  treatment,  even  section  of  the 
nerve;  the  third  requires  complete  division  of  the  nerve;  the  fourth 
is  relieved  by  enlargement  of  the  Avound. 

2.  Spasms  of  the  muscles  ^  are  frequent  complications,  especially 
of  amputation  and  resection  wounds  ;  the  startings  of  the  limb  are 
often  among  the  most  distressing  symptoms;  they  occur  as  the  patient 
falls  asleep  and  the  influence  of  the  will  on  the  muscles  ceases,  and 
the  pain  remains  until  the  muscles  are  at  rest ;  at  any  time,  uncon- 
trollable quiverings  and  tremblinrrs'of  the  muscles  may  ensue,  and 
lead   to   painful    spasms.     The  remedy   is   posture   and  rest  of  the 

1  S.  D.  Gross :  J.  Croft.  2  Sir  J.  Paget. 


THE   lUCPA/Il.  71 

wouiuk'il  part,   sustaineil    by    splints,  or    otliL-r  appliances,   and   as- 
sisted liy  opium  or  oilier  ano(l\iies. 

3.  Delirium  tremens,  followini^  injuries,  and  surgical  operations 
on  drunkards,  or  on  persons  of  intenij>erate  liabits,  is  due  to  shock 
and  its  reaction,  and  the  deprivation  or  stinting  of  stimulants  which 
induce  a  peculiar  iuipairuicnt  of  the  essential  elements  of  the  nervous 
structures.^  The  symptoms  usually  apjjcar  within  two  or  three  days 
after  the  opei'ation;  at  first  the  patient  is  restless,  sleepless,  and 
talkative;  then  he  has  hallucinations  and  illusions  of  siglit  and  hear- 
ing, which  lead  to  attempts  to  get  out  of  bed  and  escape  reptiles  and 
vermin,  and  to  answer  imaginary  calls;  next  there  is  trembling  of 
the  tongue,  hands,  and  liuibs;  the  skin  is  moist  and  cool;  the  tem- 
perature normal;  the  tongue  coated;  the  breath  olfensive;  the  eyes 
suffused.  As  the  condition  is  one  of  debility,  the  great  object  of 
treatment  is  to  enable  the  patient  to  take  and  to  assimilate  a  sulhcient 
quantity  of  proper  nourishment.'^  The  aim  should  be  to  fortity  and 
stimulate  the  functions  of  the  brain  ;  mild  preparatory  purgatives 
may  be  required  for  the  young  and  robust,  but  the  debilitated  must 
be  sustained  from  the  first;  the  typical  stimulant  is  easily  digested 
food, 3 and  it  is  imperative  that  it  be  given  regularly  and  continuously; 
the  most  desirable  foods  are  milk  with  lime-water,  soup  or  broth 
with  bread  in  it,  raw  eggs  beaten  up,  concentrated  meats:  irritation 
of  the  stomach  requires  ice,  soda  water,  and  other  aerated  drinks; 
the  narcotic  stimulants  are  useful,  of  which  opium  and  cannabis 
indica  arc  most  valual)le  ;  opiates  may  always  be  administered  in 
the  form  of  morphia  hypodermically  injected  in  the  dose  of  Jj^  to  ^, 
or  ^  a  grain  ;  if  the  circulation  is  enfeebled,  ext.  cannabis  indica 
should  be  uiven  in  doses  of  ^  to  ^  a  grain;  alcohol  should  not  be 
given  to  young  subjects,  nor  in  any  case  where  it  can  be  dispensed 
■with.3  In  some  cases  it  may  be  found  necessary  to  give  "-ood  ale, 
porter,  or  wine,  with  solid  food.^  Bromide  of  potassium  condiined 
with  the  hydrate  of  chloral,  the  former  twenty  to  thirty  o-rains  and 
the  latter  fen  to  fifteen  grains  at  a  dose,  is  a  valuable  remedv  in 
quieting  nervous  a<xitation.  Restraint  should  be  made  by  an  attend- 
ant and  licit  by  confinenK'nt  with  cords  or  sfraisht  jacket. 

4.  Delirium  nervosum^  is  allied  to  delirium  tremens,  but  the 
trembling  is  absent  ;  it  is  a  state  of  excessive  nervous  exaltation, 
without  fever, ^  occurring  after  injuries  or  operations  attended  by 
severe  shock  or  loss  of  blood.  It  generally  appears  quite  suddenly, 
within  the  first  twenty-four  or  forty-eight  hours  after  the  application 
of  the  exciting  cause,  and  rarely  lasts  more  than  five  or  six  davs;  it 
may  appear  at  a  later  period  as  a  result  of  exliaustin^;  su|)puration, 

1  .1.  Proft.  2  A.  W.  Barclav.  3  p.  ^v.  Anstie.  •»  Dupuvtrea. 

6  T.  Hillroth. 


72  OPERATIVE   SURGERY. 

and  may  even  recur.  The  symptoms  are  confused,  wandering,  or 
flighty  state  of  mind;  excessive  vigilance;  incoherency  of  speech  and 
manner;  absence  of  fever;  moist  skin;  quiet  pulse;  indifference  to 
pain;  wild  expression  of  the  eyes;  intolerance  of  light,  noise,  and 
the  presence  of  attendants;  poor  appetite;  costive  bowels;  scanty 
urine.^  The  treatment  should  be  sustaining  and  tranquillizino-;  me- 
chanical restraint  may  be  required ;  remove  every  source  of  irrita- 
tion; correct  any  derangement  of  the  digestive  organs;  give  nourish- 
ing food  and  tonics;  aiimini>ter  morphia  liyj)odermically. 

5.  Tetaiius  is  a  spasmodic  affection  of  the  muscles,  (hie  to  irrita- 
tion of  the  spinal  medulla  and  portio  minor  of  the  fifth  pair.^  The 
chief  causes  are  cold  and  damp,  and  the  injury  of  the  ojjeration.^ 
The  muscles  of  the  jaw  alone  may  be  affected,  trismus,  or  other 
groups  may  be  involved.  The  symptoms  appear  as  late  as  the  third 
or  fourth  day  after  the  injury,  often  later.  In  a  well-marked  case 
they  develop  in  the  following  order:  (1)  there  is  a  sense  of  suf- 
fering from  a  cold,  with  sore  throat  and  stiff  neck,  an  uneasy  sensa- 
tion and  stiffness  of  the  muscles  of  the  lower  jaw  and  tongue,  rigid- 
ity of  the  back  of  the  neck  ;  (2)  difficulty  and  pain  in  masticating 
and  swallowing  food,  fixed  and  closed  state  of  the  lower  jaw,  severe 
pain  with  every  effort  to  open  the  mouth;  (3)  convulsive  cramp  in  all 
the  affected  muscles  on  any  attempt  to  swallow;  (4)  sudden,  violent, 
and  continued  jiain,  increased  at  short  intervals  by  spasm  extending 
from  the  ensiform  cartilage  to  spine  in  the  situation  of  the  dia- 
phrao-m  ;  (5)  constricted  and  hardened  state  of  the  abdominal  mus- 
cles, friving  the  sensation  of  a  board  to  the  hand;  (6)  all  of  the  volun- 
tary muscles  become  involved,  the  head  is  thrown  back  and  fixed, 
the  extremities  become  fixed  and  rigid,  the  shoulders  are  drawn 
forward,  the  countenance  is  pale,  anxious,  and  contracted,  and  dis- 
figured with  the  tetanic  grin;  (7)  the  spasms  become  more  and  more 
frequent  and  violent,  with  hurried  and  laborious  respiration,  and 
quick,  small,  and  irregular  pulse;  (8)  the  spasms  may  not  be  sudden, 
but  may  gradually  draw  parts  into  the  form  of  a  bow ;  (9)  at  the 
close  the  whole  face  becomes  distorted  and  disfigured,  the  larynx 
forcibly  drawn  up,  and  in  the  majority  of  instances  the  case  termi- 
nates in  a  paroxysm  of  spasm  ;  (10)  the  intellectual  faculties  remain 
unimpaired.*  The  bodily  temperature  varies  greatly  in  different 
cases.  The  treatment  can  be  only  symptomatic,  owing  to  the  un- 
certainty as  to  its  etiology;  the  most  marked  indication  is  to  allevi- 
ate the  acute  course,  and  make  it  more  chronic:  narcotics  with  opium 
and  chloroform  are  most  often  employed,  the  former  in  large  doses 
as  by  hypodermic  injections  of  morphia,  and  the  latter  during  the 
spasm;''    the  opium  never  removes  the  cause,  though  it  will  prevent 

1  S.  D.  Gross.  -  T.  BiUroth.  3  c.  B.  RadclifEe.  *  Morgan. 


THE   CICATIUZATIOX.  73 

the  effects,  and  does  fjood  by  not  allowing  the  symptoms  to  do  harm.^ 
The  Calabar  bean  has  proved  more  useful,  perhaps,  than  other  rem- 
edies, when  given  in  such  do.-es  as  to  paralyze  the  voluntary  muscles.* 
Almost  every  other  internal  remedy  has  been  successively  tried, 
but  no  one  individual  medicine  has  proved  an  appropriate  means  of 
cure  ;  they  have  been  useful  oidy  as  they  have  rendered  the  i)ar- 
oxysms  less  severe,  and  enabled  the  patient  to  lesist  the  exhaustion 
caused  by  spasmodic  action.  It  must  be  remembered  that  the  disease 
will  run  a  certain  course,  having  its  period  of  accession,  its  height 
of  intense  activity,  and  its  gradual  decline;  nothing  seems  to  check 
its  progress,  or  control  its  unvarying  and  too  often  fatal  career; 
all  that  can  be  done  is  to  give  the  patient  as  much  strength  as  pos- 
sible, to  avoid  ;ill  useless  applications  and  internal  reine<lies,  and 
all  exposures  to  excitement  and  cold,  and  to  watch  day  and  night  in 
order  to  protect  and  sustain  him.^ 


CHAPTER  XL 

THE   CICATRIZATION. 

Though  the  morphological  changes  are  the  same  in  wounds  heal- 
ing by  first  and  second  intention,*  it  is  in  the  open  wound,  healin" 
by  granulation,  that  the  several  steps  of  the  normal  process,  and  the 
various  complicating  affections,  may  be  most  advantageously  studied. 

I.    NORMAL  CICATRIZATION. 

llie  growth  of  granulations  and  of  vessels  going  on  beneath  the 
suppuration  reaches  its  physiological  limit  when  they  have  arrived 
at  the  level  of  the  surrounding  skin;  when  this  is  attained,  suppura- 
tion diminishes,  and  the  formation  of  the  epidermic  covering,  the 
skinning  over,  commences  from  the  borders.^  In  association  with 
shrinking  of  the  vessels  and  of  the  tissue  of  the  granulations  con- 
taining them,  the  superficial  extent  of  the  wound  diminishes,  and  at 
the  same  time  the  skin  surrounding  it  becomes  drawn  towards  the 
centre ;  at  the  part  where  the  skin  and  granidations  meet,  the  secre- 
tion of  pus  becomes  somewhat  diiiiinished,  first  a  dry,  red  border 
about  one  and  a  half  lines  in  breadth  forms  and  spreads  towards  the 
wound,  and  in  proportion  as  this  advances  and  covers  the  granulat- 
ing surface,  a  clear,  bluish-white  border  follows  immediately  after  it, 
and  is  transforme<l  into  epidermis.*  This  bluish-white  border,  ad- 
vancing from  the  edges  of  the  wound  towards  the  centre,  is  made  up 
of  young  ei)idermis  which  allows  the  subjacent  blood-vessels  to  shine 

1  J.  Hunter.      2  E.  Watson.      3  a.  iVlaiid.      ■»  T.  Ijilliolh.      o  M.  Kaposi. 


74  OPERATIVE  SURGERY. 

tlirouiili  its  thin  layer  with  a  bluish  tint  ;  at  last  the  whole  is  cov- 
ered with  epidermis,  consisting  at  first  of  mere  polygonal,  less  flat- 
tened, and  nucleated  cells,  which  are  frequently  shed;  later  they 
appear  more  flattened,  are  in  thicker  layers,  and  have  a  longer  du- 
ration ;  the  scar,  therefore,  assumes  a  bluish  tint  so  long  as  it  is 
young ;  later,  in  proportion  as  the  epidermic  layers  covering  it  be- 
come thicker,  and  a  greater  number  of  its  vessels  and  those  situated 
at  a  o-reater  depth  shrivel  up  and  become  obliterated,  it  appears 
whiter,  smoother,  and  shining;  the  scars  continue  to  contract  for 
many  months  and  years. ^  The  rate  of  healing  is  ordinarily  half  an 
inch  per  week,  those  wounds  healing  most  rapidly  which  correspond 
with  the  long  axis  of  the  body."'^ 

The  subjective  sensations  caused  by  the  granulations  during  nor- 
mal cicatrization,  as  well  as  by  the  fully  formed  scar,  are  inconsider- 
able ;  healthy  granulations  possess  a  certain  degree  of  sensitiveness 
to  external  irritation,  and  to  the  touch  in  pai-ticular,  but  this  is  far 
from  being  painful ;  diminished  or  increased  sensitiveness  are  there- 
fore indications  of  an  abnormal  course ;  at  the  commencement,  and 
in  the  course  of  the  cicatrization  of  wounds  of  the  skin,  an  itching 
sensation  is  often  experienced  in  the  immediate  vicinity,  which,  how- 
ever, has  no  prognostic  value;  completely  formed  scars  are  normally 
not  at  all  specially  sensitive,  though  stretching  or  mechanical  irrita- 
tion of  any  kind  may  make  them  painful.  ]\Iany  persons  complain  of 
drawino-,  tearino-,  pricking,  radiating  pains  occasionally  felt  in  scars, 
which  they  connect,  without  cause,  with  changes  in  the  weather.^ 
In  normal  cicatrization,  the  following  indications  of  treatment  should 
be  carefully  attended  to  at  every  stage:  (1)  the  granulations  must 
be  protected  from  every  possible  soin-ce  of  irritation,  as  too  fre- 
quent change  of  dressing,  too  much  movement  of  the  ])art,  filth,  re- 
tained secretions;  (2)  the  granulations  should  never  be  broken  so  as 
to  bleed,  for  such  lesions  are  liable  to  be  followed  by  the  absorption 
of  septic  ferments  ;3  (3)  the  direction  and  shape  of  the  cicatrix  should 
be  so  moulded  or  shaped  by  the  dressing  as  least  to  impair  the  func- 
tion and  symmetry  of  the  part.* 

II.    DISEASED   GRANULATIONS. 

The  granulating  surface  is  liable  to  undergo  many  changes  which 
modify  the  process  of  cicatrization.  The  formation  of  the  epidermis 
may  thus  be  interfered  with,  or  the  epidermis  alone  may  suffer  delay 
or  interrui)tion.^ 

1.  Erethitic  granulations  ^  are  characterized  by  great  pain  on 
the  slightest  provocation  ;    are  very  proliferous,  and  readily  bleed  ; 

1  M.  Kaposi,     'i  G.  AV.  Calleiuler.     ^  j.  Lister.     ^  g.  J.  Swerchesky;  Langer. 
5  T.  Billruih. 


THE   CICATRIZATION.  75 

occasionally  they  are  so  sensitive  as  not  to  endure  the  slightest  touch, 
nor  any  dressing,  but  a  less  degree  of  sensitiveness  is  more  common. 
The  cause  is  uncertain,  but  may  be  due  to  a  peculiar  degeneration  of 
the  ends  of  the  nerves  at  the  floor  of  the  wound.  The  remedies  are 
soothing  applications,  almond  oil,  spermaceti  ointment,  poultices  of 
linseed  meal,  or  warm-water  compresses;  narcotic  appllL-ations  are 
of  little  benefit.  If  these  applications  do  not  succeed,  the  entire  gran- 
ulating surface,  or  at  least  the  painful  part,  must  be  destroyed  with- 
out delay  by  caustics,  as  nitrate  of  silver,  caustic  potash,  or  the  hot 
iron,  or  by  excising  the  entire  surface  with  the  knife,  the  j)atient 
being  anicstlietized;  if  hysteria  or  anaemia  exist,  tonics,  as  iron  and 
quinine,  remedies  whieh  relieve  general  irritability,  valerian,  asa- 
foetida,  i-liould  l)e  ciiipldvcd. 

2.  Croupous  granulations  ^  form  a  yellow  rind  on  part  of  the 
surface,  readily  detached,  and  composed  of  pus  cells  very  firmly  ad- 
herent to  each  other.  The  membrane  re-forms  even  a  few  hours  after 
its  removal,  and  this  is  repeated  for  several  days,  till  it  either  disap- 
pears spontani'ously,  or  finally  ceases  on  cauterization  of  the  affected 
part.  If  disease  of  the  granulating  surface  be  accom[)anied  by  swell- 
ing, great  pain,  and  fever,  there  is  a  true,  acute  inflammation  of  tlie 
wound,  which  usually  ends  in  sloughing  of  tlie  diseased  granulations, 
llie  treatment  is  jjurely  local;  any  causes  of  new  irritation  should  be 
sought  out  and  prevented  ;  the  fibrinous  rinds  should  be  daily  re- 
moved, and  the  exposed  surface  cauterized  with  nitrate  of  silver,  or 
painted  with  tincture  of  iodine. 

;].  Indolent  granulations  ^  may  become  completely  papillary, 
and  form  a  flat  surface,  which,  instead  of  being  vividly  colored,  is 
of  a  brownish-red  tint,  finely  granular,  secretes  a  little  thin  serous 
pus,  and  frequentl}',  owing  to  drying  up  of  this  secretion,  appears  as 
if  smeared  over  witli  varnish,  dry,  glistening,  and  iridescent;  or 
the  surface  of  the  wound  has  a  shining,  oily  appearance,  or  its 
upper  layers  break  down  into  a  fatty,  greasy  pulp;  in  this  indolent 
condition  the  wound  may  remain  for  weeks  or  months  without  nuirk- 
edly  altering  its  level,  and  without  cicatrization  taking  place  from 
the  periphery  inwards.  Or  the  granulations,  having  shot  forth  lux- 
uriantly, may  be  easily  lacerated,  bleed  freely  and  frequently;  haeni- 
orrha'iic  effusion  takes  place  into  them,  by  which  they  become  of  a 
bluish-red  color,  degenerate,  shrivel  up,  decay  into  shreds,  and  are 
cast  off;  or  the  abundant  granulations  are  dropsical,  soaked  with 
fluid,  of  a  pale  rose  tint,  and  transparent.  Such  granulations  do  not 
favor  cicatrization,  as  they  do  not  afford  a  sulHciently  firm  support  for 
the  advancing  border  of  epidermis,  and  are  easily  destroyed.  This 
condition  of  the  granulations  occurs  more   often   in   persons  of  im- 

1  T.  Billroth.  2  m.  Kaposi. 


76  OPERATIVE  SURGERY. 

paired  nutrition  from  whatever  cause,  as  anaemia,  cachexia,  scrofula; 
or  if  suffering  from  febrile  excitement;  or  it  may  be  due  to  local  irri- 
tation of  the  wound,  as  pressure,  friction.  Indolent,  torpid  granula- 
tions maj'  be  excited  by  slightly  stimulating  applications,  as  unguent 
basilicum,  or  slightly  caustic  remedies;  in  obstinate  cases  it  is  advis- 
able to  destroy  the  whole  surface  of  the  wound  down  to  the  healthy 
tissues  by  means  of  some  energetic  caustic,  as  the  hot  iron,  nitrate  of 
silver,  chloride  of  zinc,  caustic  potash,  so  as  to  secure  a  more  active 
formation  of  granulations  from  healthy  tissues;  swollen  granulations, 
about  to  become  disorganized,  may  be  advantageously  destroyed,  to 
ascertain  depth,  by  the  same  means.  Additional  remedies  are  slight 
cauterization  frequently  repeated;  dusting  on  powdered  alum;  pamt- 
ing  with  a  concentrated  solution  of  nitrate  of  silver,  or  applying  the 
solid  stick  ;  an  ointment  containing  two  grains  acetat.  copper  to  the 
drachm;  or  a  lotion  of  caustic  potash,  one  or  two  grains  to  the  ounce 
of  distilled  water;  or  an  ointment  of  red  precipitate,  two  or  three 
grains  to  the  drachm,  or  of  nitrate  of  silver,  thirty  grains  to  the 
ounce.  After  the  surface  of  the  wound  has  been  freed  from  any  dead, 
gangrenous,  diphtheritic,  or  hasmorrhagic  coating,  and  granulations  are 
seen  springing  up  everyAvhere,  we  have  a  valuable  addition  to  our 
means  of  treatment  in  the  transplantation  of  epithelium  and  portions 
of  skin. 

The  procedure  i  is  as  follows:  The  more  healthy  the  granulation  the  more  cer- 
tain is  success.  It  is  not  material  from  what  point  of  the  body  the  graft  is  taken, 
but  it  will  be  found  most  convenient  to  take  it  from  some  portion  which  is  thin 
and  flexible,  as  the  sides  of  the  chest  and  the  front  of  the  legs  and  arms.  The 
best  and  simplest  method  of  taking  the  graft  is  with  the  point  of  a  common 
needle  to  raise  the  integument,  and  with  the  knife  or  scissors  cut  out  a  small 
piece  of  true  skin,  without  adipose  tissue;  there  need  be  no  bleeding.  As  the 
pieces  should  be  very  small,  subdivide  those  taken  several 
times;  lay  these  fragments  upon  the  granulations  with  the 
raw  surface  downward,  when  practicable,  though  this  po- 
.sition  is  not  absolutely  necessary;  place  the  first  near  the 
(margin,  and  the  remainder  about  one  inch  apart,  as  this  is 
the  (H-dinary  limit  of  their  growth;  cover  them  with  com- 
mon adhesive  strip  and  bandage,  or  apply  oiled  gutta-per- 
cha skin,  or  the  antiseptic  dressings.  Keep  the  part  at 
rest  for  three  days,  when  the  dressings  are  to  be  very  care- 
fullj'  removed,  and  the  sore  made  clean  with  tepid  soaped 
water  applied  with  a  stream;  the  surface  should  n'lt  be 
rubbed.  The  subsequent  treatment  is  that  of  an  ordinary 
ulcer.  When  the  dressings  are  tirst  removed,  what  appears 
I'"iG.  47.  to  be  the  grafts  may  be  seen  lying  where  they  were  orig- 

inally placed,  or  floating  loosely  about;  sometimes  they 
have  disappeared  altogether.  On  the  seventh  to  the  tenth  day  there  is  a  bluish- 
white  opaque  appearance  at  the  seat  of  the  successful  graft,  which  indicates  skin 

1  F.  H.  Hamilton;  M.  Reverdin. 


THE   CI CA  Till Z A TION. 


77 


formation.  At  tlie  same  time  there  is  a  projection  of  new  skin  from  llie  margin 
of  the  ulcer  towards  the  nearest  graft,  wiiicii  (inally  forms  a  bridge,  and  the  graft 
is  lost  in  the  surrounding  integument,  and  becomes  in  its  turn  the  outer  margui 
of  the  greatly  diminisiied  ulcer.  Finally,  all  the  grafts  coalesce,  each  contribut- 
ing an  inch  or  less  to  the  completion  of  the  cicatrization. 

By  grafting,  the  most  extensivu  open  wound,  as  complete  denuda- 
tion of  the  head  (Fig.  47),  a  wound  which  could  not  by  any  other 
method  be  completely  healed,  vapidly  cicatrizes  around  its  whole 
mandn  (Fig.  48),  and  becomes  in  no  considerable  time  tiimly  re- 
paired. 

4.  Exuberant  granulations  ^  exist  when  they 
rise  above  the  level  of  the  skin,  and  lie  over  the 
ed'i^es  of  the  wound  like  fungus.  They  are  usually 
very  soft;  the  pus  secreted  is  mucous,  glairy,  te- 
nacious, contains  fewer  cells  than  good  pus,  and 
most  of  the  pus  cells,  like  granulation  cells,  are 
filled  with  fat  globules  and  mucous  material,  which 
is  also  more  abundant  than  normal  as  intercellular 
substance.  The  development  of  vessels  may  be 
very  prolific,  and  the  fragile  tissue  often  bleeds  on 
the  slightest  toucli,  but  occasionally  the  granula- 
tions are  of  a  very  dark  blue  color;  in  other  cases  the  development  of 
vessels  is  very  scanty,  the  surface  light  red.  or  in  spots  even  has  a 
yellowish,  gelatinous  appearance  in  anaemic  persons,  and  the  young 
and  old.  The  cause  of  proliferating  granulations  may  be  a  foreign 
substance  in  the  wound,  rigidity  of  surrounding  skin,  large  wounds 
whidi  contract  slowly.  Cicatrization  will  not  progress  properly 
until  the  granulations  liave  been  brought  to  the  level  of  the  skin. 

For  this  purpose,  the  daily  application  of  nitrate  of  silver  along  the  edges, 
and  its  repetition  when  the  white  slough  which  it  forms  separates,  is  very  useful; 
also  powdered  red  oxide  of  mercury  sprinkled  daily  on  the  surface.  Astrin- 
gent lotions,  as  decoction  of  oak  or  cinchona  bark,  and  lead  water  are  useful 
where  the  proliferation  is  less;  compression  with  adhesive  plasters  acts  well 
occasionally.  If  the  granulations  are  exceedingly  dense  and  large,  they  may  be 
cut  off  with  scissors,  the  bleeding  being  arrested  by  charpie. 


III.     Tin:  CICATRIX. 

There  are  many  variations  in  the  cicatrix  which  have  a  morbid 
condition  or  tendency,  and  require  care  and  treatment. 

1.  The  Defective  cicatrix^  remains  thin,  weak,  vascular,  moist, 
easily  breaking  out.  and  yielding  so  as  to  expose  the  subjacent  struc- 
tures; it  indicates  a  failure  or  incompleteness  in  the  last  stages  of  heal- 
ing, a  deficient  development  of  cuticle,  and  too  little  contraction  of  the 
granulations  or  bond  of  adhesion.  Such  scars  are  most  frequent  after 
1  T.  Billroth.  2  Sir  J.  Paget. 


78  OPERATIVE  SURGERY. 

wounds  healed  by  granulations  that  have  become  cedeniatous,  soft, 
and  puffy,  whether  through  disease  or  the  constriction  due  to  the 
contraction  of  tissues  healing  round  them  ;  they  are.  common  after 
wounds  that  heal  slowly,  and  in  weakly  patients.  Such  scars  are 
prevented  by  cauterizing  exuberant  and  cedematous  granulations  with 
nitrate  of  silver  or  sulphate  of  copper,  and  dressing  them  with  solu- 
tions of  those,  or  other  astringent  lotions. 

Similar  solutions  are  useful  for  the  scars  themselves,  as  also  the  bichloride  of 
mercury  in  spirit.  Scars  should  always  be  warmly  and  dryly  covered,  as  they 
are  sensitive  to  cold,  and  this  protection  may  be  required  for  manj'  months. 

2.  The  exuberant  cicatrix  ^  presents  various  forms  in  its  frequent 
combinations,  with  their  indurations  and  degeneracies.  In  its  simplest 
condition,  it  appears  only  as  a  thick  or  lumpy  scar,  which  projects 
from  tlie  surface  instead  of  being  plane  or  depressed  ;  it  sometimes 
follows  the  operation  for  hare-lip,  and  here  shows  its  worst  quality, 
as  it  is  unsightly  and  apt  to  contract  long  after  its  formation.  Sim- 
ilar scars  occur  after  vertical  wounds  through  the  eyelids.  These 
scars  cannot  always  be  avoided,  for  they  are  sometimes  due  to  con- 
stitutional defects,  as  in  scrofulous  persons;  but  when  their  deformity 
would  be  troublesome,  the  most  scrupulous  means  should  be  adopted 
to  obtain  inuncdiate  union  of  the  wound.  When  tiny  are  formed,  the 
absorption  of  the  lowly  organized  new  siructures,  of  which  the  scars 
are  composed,  is  best  promoted  by  the  repeated  a[)plication  of  stimu- 
lants or  vesicants,  as  the  strong  solution  of  iodine,  or  blistering  fluid. 

3.  The  adherent  cicatrix  ^  adheres  too  much  and  too  long  to  the 
adjacent  structures,  and  thus  falls  short  of  that  stage  of  improvement 
in  which  there  is  a  gradual  loosening  of  the  tissue,  a  part  of  the  nor- 
mal process,  which  at  first  unites  a  scar  to  the  parts  beneath  or  near 
it.  The  persistence  and  excess  of  scar-tissue  existing  in  the  failure  of 
this  loosening  process  are  often  grave  inconveniences,  either  from 
deformity,  or  by  rendering  the  scars  liable  to  ulceration,  or  by  inter- 
fering with  their  nutrition.  The  relief  of  this  condition  is  difficult; 
the  best  means  are  friction,  shampooing,  steaming,  and,  if  the  tissue 
is  abundant,  stimulants  or  vesication;  but  all  remedies  must  be  used 
very  gently  when  the  scar  adheres  to  bone. 

4.  The  contracted  cicatrix ^  may  follow  any  wound,  but  is  most 
frequent  in  those  which  involve  strong  fascias,  and  after  deep  burns; 
in  some  cases  the  scar  appears  only  to  contract,  but  in  more  it  be- 
comes very  dense,  hard,  toughly  fibrous,  nodular,  and  lumpy,  and 
usually  adheres  closely  to  the  structures  near  it.  The  certainty  of 
considerable  contraction  of  the  scar  of  a  wound  healed  by  adhesion 
or  granulation,  and  the  possibility  that  it  may  be  excessive,  must  be 
reo'arded  in  every  surgical  wound  involving  parts  in  which  contrac- 

1  Sir  J.  Paget. 


THE   CICATRIZATION.  79 

tions  wouM  be  iiiisfliicvoiis.  The  length  of  a  wound  should,  if  pos- 
sible, be  in  that  direction  in  which  subsequent  shortening  will  be 
least  important;  and  it  may  often  be  necessary  to  make  provision 
against  contraction  of  scars  by  lateral  or  other  incisions,  or  by  plastic 
operations.  When  no  provision  can  be  made,  the  lualing  must  be 
carefully  watched,  and  some  elongating  force  must  be  applied  in  the 
direction  to  counteract  the  contraction  ;  if  near  the  joints,  the  tend- 
ency to  contraction  must  be  overcome  by  splints  with  screws,  or 
elastic  bands  or  cords,  whose  persistent  recoil  after  being  stretched 
will  exercise  a  force  more  powerful  and  not  less  constant  than  that 
of  the  scar.  Elongation  may  be  assisted  by  frequent  apj)lication  of 
moist  heat,  or  sliauH)()oin'T,  and  other  means  of  softening;  and  causing 
partial  absorption  of  the  scar-tissue  ;  the  treatment  must  be  con- 
tinued as  long  as  the  disposition  to  contract  exists.  If  the  contrac- 
tion finally  impairs  the  function  of  a  part,  it  may  be  necessary  to 
dissect  out  the  cicatrix  and  transplant  healthy  skin  to  the  wound. 

5.  The  painful  cicatrix^  is  most  common  after  amputation,  but 
may  occur  iu  the  scar  of  any  wound.  The  cause  of  the  pain  is  often 
obscure,  and  the  more  so  owing  to  its  commencement  in  some  cases  a 
long  time — it  may  be  years  —  after  the  healing  of  the  wound,  and 
without  visil)ie  change  in  the  scar.  But  in  stumps  it  is  nearly  certain 
that  the  pain  is  ilue  to  a  morbid  condition  of  the  ends  of  one  or  more 
of  the  divided  nerves;  not  to  the  bulbous  swelling  common  in  the 
healing  of  nerves,  generally  painless,  but,  to  morbid  adhesions  of  the 
nerves  to  the  end  of  bone  or  to  skin,  so  that  they  are  kept  in  constant 
irritation,  or  are  inflamed.  In  other  cases  no  such  condition  can  be 
found,  and  the  cicatrix  can  only  be  called  neuralgic.  When  the  pain 
of  a  scar  depends  upon  adhesions  or  other  such  morbid  condition  of 
the  nerve.^  subcutaneous  division  maybe  practiced  ;2  when  wounds 
have  been  allowed  to  heal  with  the  linib  bent,  or  otherwise  misplaced, 
the  neuralgia  seems  to  be  due  to  compression,  and  recovery  follows 
restoring  the  normal  movements  with  douche  and  friction. 8  When 
these  measures  fail,  or  the  case  is  one  of  obscure  and  severe  neural- 
gia, the  treatment  must  be  that  of  ordinary  neuralgic  affections, 
namely,  quinine,  belladonna,  and  other  narcotics,  the  local  applica- 
tion of  anodynes,  or  excision. 

1  Sir  .J.  Paget.  2  h.  Hancock.  8  s.  W.  Mitchell. 


II. 

THE     OSSEOUS     SYSTEM. 

THE   BONES;    THE  JOINTS. 

CHAPTER  XIL 

THE   INJURIES   OF   BONES. 

Violence  applied  to  bone  results  in  lesions  analogous  to  those 
produced  by  the  same  causes  on  the  soft  tissues.  Contusion  may  be 
followed  by  the  inflammatory  process,  and  the  results  ajjpear  among 
the  diseases  of  bone.  Fracture  is  the  counterpart  of  the  wound  of 
the  soft  tissues  and  demands  immediate  care,  either  in  operative 
procedures  or  in  the  employment  of  adjusting  and  retaining  appli- 
ances. This  lesion  is  divided,  for  practical  purposes,  into  (1)  the 
Simple  Fracture,  (2)  the  Compound  Fracture,  (3)  the  Shot  Frac- 
ture. 

I.   SIMPLE  FRACTURE. 

Endeavor,^  on  first  approaching  a  patient  suffering  from  fracture, 
to  inspire  him  with  a  confidence  that  he  is  not  to  be  unnecessarily 
hurt;  sit  quietly  beside  him,  and  inquire  minutely  into  all  the  cir- 
cumstances relating  to  the  accident ;  remove  the  clothes  from  the 
injured  limb  with  the  utmost  care  ;  notice  its  position,  contour, 
points  of  abrasion,  discoloration,  or  swelling;  pass  the  fingers  lightly 
along  the  surface  of  the  limb,  pressing  more  firmly  at  points  Avhere 
there  are  appearances  of  injury ;  finally,  to  solve  all  doubts,  grasp 
the  limb  so  as  to  make  traction  of  the  lower  fragment,  rotate  to 
obtain  crepitus,  and  make  lateral  motions  to  indicate  the  false 
point  of  motion  ;  in  the  application  of  the  necessary  dressings,  let 
gentleness  and  a  manifest  regard  for  the  patient's  sufferings  charac- 
terize every  act ;  and,  throughout  the  subsequent  treatment  of  the 
case,  proceed  slowly,  thoughtfully,  and  systematically,  for  rude  and 

1  F.  H.  Hamilton. 


THE  INJURIES   OE  BOXES.  81 

awkward  manipulations,  by  which  pain  is  necdlL-ssly  inflicted,  are 
frequent  sources  of  inflammation,  suppuration,  and  j^angiene. 

In  the  simple  fracture  the  bone  is  broken  at  a  sinide  jioint,  the 
lesion  is  subcutaneous,  and  no  other  important  i»arts  are  involved; 
it  is  therefore  in  the  most  favorable  condition  for  repair. 

The  signs  of  fracture,  on  which  reliance  can  be  placed,  are:  (1) 
crepitus,  obtained  by  rotating  the  lower  fragment;  (2)  preternat- 
ural mobility,  produced  by  lateral  movements  of  the  fragments;  (3) 
spontaneous  displacement  when  reduction  of  the  fragments  lias  been 
effected.  The  treatment  is  rej)lacemeMt  of  the  fragmenis,  and  main- 
tenance of  their  extremities  in  apposition.  Replacement  should  be 
effected  as  soon  as  possible  after  the  accident.^  The  fragments 
may  usually  be  jjlaced  in  coaptation  by  extension  and  counter-exten- 
sion with  the  hands  ;  but  should  such  means  fail,  anaesthetics  must 
be  used,  and  even  pulleys.^  Maintenance  is  accomplished  by  side 
or  eoaptating  splints,  by  long  or  extending  splints,  by  the  weight 
and  pulley,  by  plastic  apparatus,  or  by  a  combination  of  these 
methods.  Of  the  several  appliances,  the  plastic  apparatus,  in  its 
various  forms,  most  effectually  secures  and  maintains  coaptation,  but 
used  as  a  bantlage  when  the  fracture  is  accomjianied  with  such  in- 
jury to  the  soft  parts  as  to  render  subsequent  inflammation  inevi- 
table or  probable,  this  form  of  dressing  exposes  to  congestion,  stran^^u- 
lation,  and  gangrene. ^  As  safety  in  the  use  of  this  dressing  depends 
much  upon  the  skill  and  care  of  the  surgeon,  the  rule  should  be 
never  to  resort  to  it  unless  familiar  with  all  its  peculiarities,  and  in  a 
position  to  give  the  case  necessary  care.^  When  employed,  the  pro- 
visional callus  will  always  be  less,  and  hence  firmness  will  result 
later,  yet  the  formation  of  definitive  callus  will  not  be  disturbed.* 
But  these  objections  do  not  apply  to  the  different  forms  of  L'vpsum 
splints,*  which  can  be  readily  and  perfectly  adapted  to  support  the 
limb  and  not  endanger  it  by  strangidalion;  these  splints  should  be 
applied  in  the  first  stage  of  the  case  ;  swelling  from  contusion  and 
subcutaneous  laceration,  uncomplicated  with  lesion  of  the  vascular 
trunks,  is  not  an  objection  to  the  immediate  application  of  the  ap- 
])aratus;  on  the  contrary,  the  support  ami  enforced  rest  have  a  bene- 
ficial influence  in  controlling  swelling  and  its  consequent  pain.  As 
a  rule,  no  bandaixe  should  at  first  be  applied  directly  to  the  skin.' 
The  dressings  adapted  to  individual  fracture  must  necessarily  vary 
very  much,  but  it  may  be  stated  as  a  principle  applicable  to  each 
case  that  that  apparatus  is  the  best  which,  whilst  it  answers  the  indi- 
cations equally  well,  exacts  the  least  amount  of  ^kill  and  attention.' 

1.  The  inferior  maxilla  may  be  fractured  at  any  point  of  the 
body  and  of  the  rami,  or  two  fractures  may  occur.      Of  the  variety 

1  F.  H.  Hamilton.  ■^  T.  Billroth.  a  a.  C  Post.         ^  J.  Croft. 

6 


82 


OPERA  TI VE   S  UR  GER  Y. 


of  apparatus  constructed,  the  most  convenient  and  serviceable  in 
general  practice  is  an  interdental  gutta-percha  splint,  moulded  to  the 
crowns  of  the  teeth,  and  an  external  gutta-percha  or 
sole-leather  cap  for  the  chin,  b^ld  in  position  bv  the 
four-tailed  bandage  (Fig.  49). 

The  following  apparatus  1  is  very  permanent:  Pass  a 
firm  leather  strap  iiniler  the  chin,  and  buckle  over  the  top  of 
the  head;  stay  it  by  two  counter-straps  of  linen  webbing; 
loop  one  of  these  upon  the  maxillary  strap  at  a  point  just 
above  the  ears,  and  elevate  or  depress  it  for  different  heads; 
buckle  this  strap  under  the  occiput  posterioi'ly,  and  across 
the  forehead  anteriorly  ;  pass  a  vertical  strap  over  the  top  of 
Fig.  49  ^^^^  \\tA(\.  in  the  line  of  the  sagittal  suture,  and  unite  the  max- 

illary and  the  occipital  strap ;  to  prevent  the  maxillary  strap  being  displaced 
backward,  fasten  a  chin-piece  to  it. 

Union  is  complete  in  three  weeks;  non-union  is  very  rare.^ 

2.  The  ribs  and  cartilages  are  more  often  fractured  in  advanced 
life;  the  displacement  is  usually  very  slight, 
and  not  easily  overcome,  but  union  takes 
place  quickly,  even  when  quietude  is  not 
secured.^  Emphysema,  due  to  injury  of 
the  lung,  is  quite  common,  and  generally 
demands  no  special  attention;  but,  if  very 
extensive,  it  may  be  necessary  to  make  an 
incision,  or  to  open  the  Avound  down  to  the 
])oint  of  fractiu-e,  to  allow  the  air  to  escape.^ 
Union  takes  place  in  about  one  month. ^ 
The  fractured  rib  may  be  efficiently  main- 
tained in  a  state  of  rest  by  the  application  of  strips  of  strong  adhe- 
sive plaster  (Fig.  50)  two  inches  broad,  extending  from  the  sternum 
to  the  spine,  covering  in  the  seat  of  injury  and  at  least  three  inches 
of  surface  above  and  below  it ;  each  strip  so  ajjplies  as  to  overlap 
half  of  the  preceding ^  (Fig-  i^O). 

If  several  ribs  are  fractured,  they  may  be  maintained  in  very  accurate  apposi- 
tion by  a  broad  band  of  adhesive  plaster.  Cut  the  plaster  of  a  width  equal  to 
one  half  the  deptii  of  the  thorax,  and  of  sufficient  length  to  extend  once  and  a 
half  around  the  body.  Place  the  strip  under  the  patient,  while  recumbent,  so 
as  to  inclose  the  lower  half  of  the  thorax,  the  adhesive  side  internal,  and 
while  he  is  in  the  act  of  forced  expiration  pass  one  end  firmly  over  the  thorax 
and  the  other  in  the  opposite  direction  over  the  first;  there  is  now  a  sense  of 
suffocation,  which  is  soon  followed  by  relief  ;  the  pain  quickly  subsides;  do  not 
change  the  dressing  until  the  cure  is  complete. 

3.  The  clavicle  fractured  is  replaced  by  supporting  the  shoulder 
•in  an  upwiu-d  and  backward  direction.  This  position  is  most  per- 
'fectly  secured  in  the  recumbent  posture,  with  an  luiyielding  pillow, 

broad,  and  long  enough  to  cover  the  whole  back  of  the  chest,  and 
1  F.  H.  Hamilton.  2  T.  Brvant. 


THE  INJURIES   OF  BONES. 


83 


Fig.  51. 


slightly  inclined  from  above  downward,  allowing  a  somewhat  greater 
elevation  for  the  head  and 
.shoulders  than  for  the  loins 
or  waist,  the  depth  of  the  up- 
per margin  not  being  greater 
than  eight  or  ten.  and  of  the 
lower  two  to  three,  inches; 
this  position  need  not  be  re- 
tained more  than  ten  to  four- 
teen days.*  No  apparatus 
completely  maintains  the  re- 
fluction  suflicicntly  long  to 
insure  a  perfect  union,  but 
the  following  method  secures 
all  the  advantages  yet  at- 
tained: Pass  a  sling  under  the 
elbow  of  the  wounded  side, 
and  tie  it  to  the  opposite 
shoulder;  insert  a  well-fitting 
axillary  pad,  but  not  so  lar^e 
as  to  be  a  fulcrum;  apply  a 
bandage  around  the  body,  so  as  to  secure  the  elbow  against  the 
trunk.2     (Fig.  51.) 

The  gypsum  bandage  3  is  useful  where  there  is  great  difficulty  in  maintaining 
parts  in  good  position  (Fig.  52);  apply  the  bandage  over  a  stout  flannel  under- 
shirt tiius:  place  the  arm  of  the  affected  side  across  tiie  thorax,  the  hand  well 
up  towards  the  shoulder;  standing  in  front,  make  severaj  turns  around  the  body 
below  the  arm  from  right  to  left,  if  the 
left  clavicle  is  fractured,  and  rice  versa; 
now  pass  one  turn  over  the  fore-arm, 
hand,  and  shoulder,  and  the  next  around 
the  arm  and  body,  and  so  alternate  until 
the  arm  is  completely  enveloped.  This 
dressing  is  entirely  comfortable,  and 
need  not  be  changed. 

Adhesive  plaster^  may  be  applied  : 
Select  strong  adhe>ive  plaster,  and  cut  it 
into  two  strips  three  or  four  inches  wide, 
but  narrower  for  children :  one  should 


/ 


L, 


be  of  length  to  encircle  the  arm  and  the 

body,  and  the  other  to  reach  from  the 

sound  shoulder  around  the  elbow  of  fiie 

fractured  side  and  back  to  the  place  of 

starting.    Pass  the  first  piece  around  the 

arm  just  below  the  a.xillary  margin,  and  Fig.  5'2. 

stitch  in  the  form  of  a  loop  sulficiently  large  to  prevent  strangulation,  leaving  a 

1  E.  nart>hurne.         -  F.  H.  Hamilton.  3  BtUevue  Hospital  Reportt. 

*  L.  A.  Sayre. 


84 


OPERATIVE  SURGERY. 


large  portion  on  the  back  of  the  arm  uncased  by  the  plaster;  draw  the  arm  down- 
ward and  backward  until  the  clavicular  portion  of  tlie  pectoralis-niajor  muscle 
is  put  suHBciently  on  the  stretch  to  overcome  the  sterno-deidomastoid,  and 
thus  pull  the  inner  portion  of  the  clavicle  down  to  its  level:  carry  the  plaster 
smoothly  and  completely  around  the  body,  and  pin  to  itself  on  the  batk  to  pre- 
vent slipping.  This  first  strip  of  plaster  fultills  a  double  purpose:  first,  by  put- 
ting the  clavicular  portion  of  the  pectoralis-major  muscle  on  the  stretch,  it 
prevents  the  clavicle  from  riding  upward;  and,  secondly,  acting  as  a  fulcrum  at 
the  centre  of  the  arm,  when*  the  elbow  is  pressed  downward,  forward,  and  in- 
ward, it  necessarily  forces  the  other  extremity  of  the  humerus  (and  with  it  the 
shoulder)  upward,  outward,  and  backward  And  it  is  kept  in  this  position  by 
the  second  strip  of  plaster,  which  is  applied  as  follows  :  Commencing  on  the  front 
of  the  shoulder  of  the  sound  side,  draw  it  smoothly  and  diagonal!}-  across  the 
back  to  the  elbow  of  the  fractured  side,  where  a  slit  is  made  in  its  middle  to 
receive  the  projecting  olecranon.  Before  applying  this  plaster  to  the  elbow,  an 
assistant  siiould  press  the  elbow  well  forward  and  inward  and  retain  it  there, 
while  the  plaster  is  continued  over  the  elbow  and  fore  arm,  pressing  the  latter 
close  to  the  ches^,  and  securing  the  hand  near  the  opposite  nipple;  crossing  the 
shoulder  at  the  place  of  beginning,  it  is  there  secured  by  two  or  three  pins. 

Union  occiir.s  with  great  rapidity,  sometimes  as  early  as  the  sev- 
enth or  tenth  day,  but  the  arm  should  be  kept  quiet  two  or  three 
weeks.  ^ 

4.  The  humerus.^  fractured  at  any  point  above  the  elbow,  should 
be  uiaintaineil  in  po.sition  as  follows:  Select  a  piece  of  leather,  gutta- 
percha, or  felt,  long  enough  to  extend  from  above  the  acromion  pro- 
cess to  the  elbow-joint,  and  wide  enougli  to  inclo.se  about  one  half 
of  the  circumference  of  the  limb;  mould  it  while  wet  to  the  outside 
of  the  arm,  and  allow  it  to  become  dry;  prepare  a  short  sj)lint  for  the 
inside  of  the  arm;  cover  each  splint  with  a  sack  of  woolen  cloth;  re- 
duce the  fracture  and  apply  the 
splints  to  the  arm  with  a  roller 
bandage,  and  secure  the  arm  to 
the  body  with  a  second  roller 
bandage  passed  around  the  lat- 
ter; flex  the  fore-arm,  and  sus- 
pend by  a  sling.  Xo  bandage  is 
required  for  the  fore-arm;  slight 
overlapping  may  be  anticipated. 
If  the  fracture  is  at  or  near  the 
elbow-joint,  the  fore-arm  must 
be  placed  and  maintained  at  a 
riiiht  angle  with  the  hutnerus  by 
means  of  a  thick  piece  of  gutta- 
FiG.  .53.  percha,  moulded  to  fit  the  shoul- 

der, arm,   and  fore-arm,  and  well  padded;  place  the   fore-arm   at  a 


1  F.  H.  Hamilton. 


Till-:  lyjL'lUES   OF  BOXES. 


85 


right  allele  wiili  the  humerus,  and  maintain  it  in  this  position  by  a 
right-angled  splint;  cover  the  gutta-percha  si)lint  with  a  woolen  or 
cotton  sack,  and  secure  it  to  the  fore-arm  by  a  roller.  In  a  case  of 
fracture  of  the  humerus  above  the  condyles,  while  extension  is  made 
secure  the  upper  portion  of  the  splint  to  the  arm  in  a  similar  man- 
ner. The  front  or  bend  of  the  elbow  should  always  be  well  cov- 
ered with  cotton  batting  before  inclosing  the  elbow-juint  in  the  turns 
of  the  roller,  to  prevent  strangulation. ^  Passive  motion  must  be 
conunenced  very  early  by  loosening  the  dressing,  supporting  the 
parts  at  the  joint,  and  making  flexion  and  extension.  If  the  frag- 
ments are  not  disturbed,  repeat  this  manoeuvre  daily. ^ 

5.  The  radius  fractured  above  the  attachment  of  the  pronator 
(piadratus  must  be  so  adjusted  that  the  proper  axis  of  the  bone  is 
maintained,  to  secure  the  restoration  of  its  normal  movements.^  The 
elbuw  should  be  semiflexed,  the  fore-arm  and  hand,  excepting  the 
fingers,  supported  between  a  dorsal  and  a  palmar  s[>lint  secured  by 
adhesive  plaster;  the  limb  should  be  accurately  fixed  in  supination 
at  an  angle  of  1"20°  by  means  of  angular  pads;  the  thumb  in  this 
position  is  brought  nearly  into  a  line  with  the  outer  fleshy  border  of 
the  supinator  radii  longus.^ 

Fracture  of  tlie  radius  within  an  inch  of  the  wrist-joint''  has  re- 
ceived the  following  elucidation  :^  The  fracture 
is  caused  by  forced  extension  of  the  hand  on 
the  fore-arm,  the  bones  of  which  constitute  two 
levers,  A  and  B  (Fig.  54),  held  together  by  the 
anterior  and  posterior  radio-carpal  ligaments  C 
and  D. 

Wlien  B  is  forcibly  carried  backwards,  as  in  extension 
of  the  hand,  liie  band  U  is  made  tense;  the  opposite  bor- 
der of  tlie  lever,  having  slipped  forward  as  far  as  the 
band  0  will  permit,  now  abuts  aj^ainst  the  lower  sur- 
face of  A,  wliich  becomes  a  fulcrum  for  tlie  further  ac- 
tion of  the  lever.     Tlie  mechanical  arranicjement  is  such        /      i  / 
tliat  an  innnense  power  maybe  exerted;   if  the  back-     /       \/\ 
ward  force  continues  to  act,  either  the  band  D  must  rup-  '^^       "  ' 
ture,  or  a  lever  be  fractured;  the  projecting  lip  upon  the      v 
upper  lever  puts  it  at  a  disadvantage;  the  band  continues 
to  sustain  the  strain,  and  the  lever  li^ives  way  (Fij;.  5-5). 
The  point  of  fracture  is  necessarily  just  above  that  por-  Fig.  54. 

lion  of  the  lever  controlled  by  the  band;  the  strain  upon 

the  lever  is  nearly  transverse.  Ry  the  powerful  leverage  which  the  extended 
hand  and  carpus  obtain  tlirough  the  strong  anterior  ligament  upon  the  lower  end 
of  the  radius,  that  portion  of  the  bone  is  literally  torn  from  it.  A  second  force, 
other  than  that  of  extension,  is  also  present,  as  an  important  and  independent 

1  F.  H.  Hamilton.        2  j.  Packard.        3  (;.  \\\  Cullender.        *  A.  Colles. 

S    L.    S.    I'lLCHEU. 


86 


0  PER A  TIVE  S UR GER Y 


factor  in  the  production  of  the  results,  namel}-,  the  forward  and  downward  im- 
pulse of  the  lower  end  of  the  radius.  A  force  compounded  of  the  weight  of  the 
body  and  the  velocity  of  the  fall  is  received 
upon  the  anterior  ligament,  and  converted  b^'  it 
into  a  force  of  avulsion.  The  new  and  tinal 
relation  of  parts  (Fig.  55)  is  lixed  by  the  peri- 
osteum covering  the  back  and  lower  portion  of 
the  radius,  reinforced  by  tibres  from  tlie  poste- 
rior ligament  and  posterior  annular  ligament 
of  the  wrist.  The  force  having  expended  it- 
self, and  the  injured  member  being  relieved 
from  the  weight,  entirely  new  forces  begin  to 
act  upon  it.  The  hand  recovering  from  the 
condition  of  forced  extension,  as  it  straightens 
or  becomes  flexed  to  the  extent  of  its  weight, 
tends  to  bring  back  with  it  the  lower  fragment 
of  the  radius;  this  fragment,  abutting  against 
the  projecting  posterior  margin  of  the  upper 
fragment y  (Fig.  56),  is  supported  as  a  fulcrum,  and  the  result  of  the  weight 

of  the  hand  is   simply   to   make   still 

fmore   tense  the   aponeurosis   which  is 
)       attached  to  it  behind.     Thus  the  char- 


(  /  yj  I     maintained,   while   immobilit}' 
'    ,{^J'    I    fragments  and  absence  of  cref 

/V\.A/''A>A    cpnnverl    (Fio-_    .^i? ^        Whpn    tliP 


Fig.  5G. 


acteristic   deformity   is   produced  and 
of   the 
repitus  is 
secured  (Fig.  57).     When  the  radius 
has  given  way,  and  the  force  of  exten- 
sion is  no  longer  arrested  by  the  inser- 
tion of  the  anterior  ligament  into  its 
broad  margin,  this  force  is  felt  strong- 
ly by  that  portion  of  the  ligament  whicli 
is  inserted  into  the  ulna  ;  the   whole 
hand,  with  the  lower  radial  fragment,  is  caused  to  move  backward  and  outward, 

as  in  supination  ;  a  strong  fasciculus 
of  the  anterior  ligament,  passing  ob- 
liquely from  cuneiform  bone  to  an- 
terior border  and  base  of  the  styloid 
process  of  the  ulna,  bears  the  most 
of  the  strain ;  through  it,  the  tend- 
ency to  supination  is  increased,  the 
rounded  head  of  the  ulna  is  made  to 
project  strongly  upon  the  front  and 
e.  Dorsal  periosteal  pseudo-liga-  inside  of  tlie  wrist,  its  styloid  process 
y.    Point  of  entanglement,     g-  becomes  approximated  to  the  radius 


Fig.  57. 
ment. 


Flexor  tendons.  upon   tlie  back  of  the  wrist,  and  in 

some  cases  is  completely  torn  off.  In 
this  position  the  parts  are  firmly  held,  all  rotation  in  either  direction  being  pre- 
vented, as  long  as  the  backward  displacement  of  the  lower  radial  fragment 
remains  unreduced. 

In  the  treatment, 1  two  classes  of  fractures  must  be  recognized, 

I  1   L.  S.  PiLCHER. 


THE  INJURIES   OF  BONES.  87 

namely,  those  witliuut  and  those  with  disphiccment.  The  first  is 
likely  to  be  called  a  sprain  and  to  be  treated  as  such;  for  immediately 
upon  the  recovery  of  the  hand  fi-om  the  over-extension  which  it  had 
sustained,  the  correspondinj^  surfaces  of  the  fragnicnts  fall  together, 
where  they  are  hehl  by  the  weight  of  the  hand  when  j)rone ;  there 
is  no  tendency  to  displacement.  The  indications  are:  (1.)  That  the 
wrist  should  be  supported  in  the  prone  position,  with  the  hand  hau'- 
ing  loosely,  and  thus  maintain  the  fragments  in  apposition.  (J.)  That 
movements  of  extension  of  the  hand  shoidd  be  limited,  lest  separa- 
tion of  the  fragments  again  occur.  The  first  indication  in  the  treat- 
ment of  the  second  form  is  to  overcome  the  displacement,  which  is  ef- 
fected as  follows:  Hend  the  hand  and  wrist  backward,  approximatino- 
the  position  in  whirh  the  parts  were  when  the  displacement  took  place, 
and  relax  the  tense  jjeriosteum.  Slight  extension  now  in  the  line  of 
the  fore-arm  is  suflicient  to  disentangle  the  rough  surfaces  of  the  frag- 
ments from  each  other,  and  moderate  pressure  ujjon  the  dorsum  of 
the  lower  fragment  causes  it  to  fall  into  line  ;  the  weight  of  the  hand 
is  now  sufficient  to  secure  perfect  apposition  of  the  fragments;  the 
periosteum  again  envelo[)S  closely  the  whole  leni^th  of  the  radius;  the 
tense  inner  fasciculus  of  the  anterior  ligament  is  completely  relaxed; 
the  radio-ulnar  movements  are  free;  the  head  of  the  ulna  has  ceased 
to  project  as  if  subliixated;  all  the  parts  have  resumed  their  natural 
relations;  the  fracture  has  become  one  of  the  first  class,  with  this 
difference  simply,  that  the  sj)rain  of  the  soft  parts  is  much  more  ag- 
gravated. Splints  are  not  always  necessary  in  the  treatment,  but 
all  the  measures  inrlicated  as  of  value  in  overcoming  the  results  of 
sprained  wrist  are  now  of  importance;  as  compression  and  support 
by  means  of  a  bandage  encircling  the  joint;  the  snug  application  of 
a  strip  of  strong  adhesive  plaster,  two  inches  wide,  so  as  to  grasp 
firmly  the  lower  extremities  of  both  radius  and  ulna,  to  restrict  effu- 
sion, and  reinforce  the  radio-ulnar  ligaments,  and  render  more  toler- 
able efforts  at  motion  of  the  wrist-joint;  massage,  early,  persistently, 
and  skillfully  applied;  motion,  early,  regular,  and  decided  in  charac- 
ter; use  of  the  hand  after  the  third  day. 

As  a  rule,  it  would  not  be  wise  to  discard  splints  altogether  in  this 
fracture,  but  they  may  in  general  be  limited  to  a  single  well-padded 
splint  on  the  dorsal  or  palmar  surface. ^  There  are  instances  of  great 
displacement  and  contusion,  in  which  two  light-pailded  splints,  care- 
fully applied  with  adhesive  strips,  are  useful. 

6.  The  olecranon  process  separated  from  the  ulna  requires  the 
straight  position  of  the  fore-arm.  Apply  a  light  but  firm  splint,  ex- 
tending from  about  four  inches  below  the  shoulder  to  the  wrist,  wide 
as  the  arm  at  its  widest  part,  thickly  padded  with  cotton  batting  to 
1  F.  H.  Hamilton. 


88  OPERATIVE  SURGERY. 

meet  the  irregularities  of  the  arm,  and  having  a  notch  cut  about 
three  inches  below  the  olecranon;  place  it  on  the  palmar  surface,  and 
apply  a  strip  of  adhesive  plaster,  the  centre  being  on  the  process 
and  the  ends  drawn  firmly  through  the  notches  and  fastened  to  the 
splint ;  retain  the  splint  in  position  by  a  bandage  or  strips  of  plaster 
passed  circularly  around  the  limb  and  splint. 

The  plaster  of  I'aris  is  applied  as  follows:  Place  the  limb  in  extreme  exten- 
sion; cover  it  with  cotton  bat- 
ting or  flannel ;  apply  three 
layers  of  bandage,  and  when 
it  is  hard  cut  out  a  large  fenes- 

„        „„  trum  over  the  olecranon:  now 

Fig.  58.  i      .  •        f     n     •         i 

apply  strips  of  adhesive  plas- 
ter, the  centres  being  over  the  upper  surface  of  the  olecranon,  and  fasten  the 
ends,  drawn  down  firmly,  to  the  sides  of  the  splint  (Fig.  58). 

7.  The  radius  and  ulna  fractin-ed  must  be  maintained  in  paral- 
lelism. Take  two  wooden  splints  of  the  length  of  the  fore-arm, 
nearly  or  quite  the  width  of  the  limb  at  its  widest  part,  properly 
padded;  apply  them  evenly  to  the  palmar  and  dorsal  surfaces,  and 
retain  them  with  two  adhesive  strips  applied  directly  around  the  limb 
and  splints. 

8.  The  femur  ^  is  liable  to  be  fractm-ed  through  the  neck,  within 
and  without  the  capsule,  below  the  trochanter  minor,  in  the  central 
portions  of  the  shaft,  just  above  the  condyles,  through  the  condyles, 
and  at  the  points  of  epiphyseal  connections.  Fracture  of  the  neck, 
including  even  cases  of  suspected  fracture,  should  be  treated  as  if  in 
a  condition  favorable  to  bony  union,  in  order  both  to  save  the  patient 
from  the  pain  and  suffering  caused  by  the  irregular  contractions  of 
the  muscles,  due  to  the  pressure  of  the  broken  fragments  against  in- 
flamed tissues,  and  to  insure  a  longer  limb  and  less  eversion  if  bony 
union  does  not  take  place.  Fractures  of  the  shaft  are  generallj'  ob- 
lique, and  the  fragments  override  from  half  an  inch  to  two  inches, 
owing  to  the  contraction  of  the  muscles  ;  fractures  just  above  the 
condyles  are  in  most  cases  oblique  from  above  downwards,  and  from 
behind  forwards.  All  of  these  forms  of  fracture  can  be  treated 
more  successfully  in  the  straight  than  in  the  flexed  position,  and  in 
nearly  all  cases  extension  is  more  effectually  made  by  the  weight  and 
pulley  than  by  any  other  method.  The  sooner  the  limb  is  put  up  and 
subjected  to  this  methoil  of  treatment  after  the  fracture,  the  better; 
suffering  is  prevented,  and  the  sufferer  made  comfortable  from  the 
outset.^  Precisely  the  same  form  of  apparatus  is  not  suited  to  all 
fractures  of  the  femur,  but  certain  modifications  are  required  to  meet 
all  of  the  indications  present.      In  an  ordinary  case,  provide  a  firm 

1    F.  H.  H.\MlLTON. 


THE  INJURIES   OF  BONES. 


89 


bed  with  a  suitahle  mattress  (Fijx.  61);  apply  a  roller  banda2;e  from 
the  toes  to  the  ankles;  next  apply  strips  of  strong  adhesive  plaster 
two  and  a  half  inches 
broad,  and  well  warmed,  'i  /-y 
to  both  sides  of  the  leg, 
extending  from  the  frac- 
ture some  iiichrs  below  the 
sole  of  the  foot  (Fig.  59); 
warm  the  ends  and  lap 
them  over  each  otjier  so 
as  to  make  a  loop  of  two  thicknesses  four  inches  lu'low  the  sole  of  the 
foot ;  in  this  loop  put  a  foot-piece  of  wood  four  inches  long  and  three 
inches  wide;  continue  the  roller  bandage  over  the  limb  to  the  groin; 
pass  a  strong  India-rubber  band  around  the  foot-piece  in  the  depres- 
sions cut  on  either  side,  and  attach  to  it  a  rope,  or  make  a  hole 
in  the  centre  of  the  block,  through  which  a  cord  is  passed  and  a 
knot  tied  so  that  it  cannot  escape ;  at  the  foot-board  arrange  a 
pulley  on  a  level  with  the  long  axis  of  the  leg;  this  pulley  may 
be  iron  or  wood,  or  even  a  large  spool,  and  may  be  fastened  on 
the  foot-board  of  the  bed,  or  in  an  iron  or  wood  upright  (Fig. 
60);  the  weights  may  be  obtained  in  sets  and  neatly  adjusted  to  the 
rope,  or  they  may  lie  made  to  ^-lide 
down  one  upon  the  other  as  the  weights 
of  the  common  scales.  Xow  apply  co- 
aptating  splints,  which  may  consist  of  ^-, 
several  narrow  strips  of  thin  board  A\ 
jiroperly  padded  and  of  such  length  as  ,aijj 
to  e.xtend  well  above  and  below  the 
fracture;  or  four  sole-leather  splints 
may  be  used  which  do  not  quite  touch 
at  their  margins,  the  external  and  in- 
ternal embracing  the  condyles;  main- 
tain these  splints  by  four  to  six  strips 
of  bandage  knotted  over  the  front 
splint,  or  by  straps  with  buckles.  The 
amount  of  weight  to  be  employed  must 
be  determined  by  the  resistance  to  be 
overcome,  and  the  toleration  of  the 
patient;  the  maximum  is  about  twen- 
ty-two pounds,  and  generally  not  over  twenty  pounds  can  be  long 
endured.  Counter  extension  is  made  by  the  wei'jht  of  the  body,  in- 
creased, if  necessary,  by  raising  ihe  foot  of  the  bed  on  blocks,  or  by 


Fio.  60. 


1  A.  Crosby. 


90 


OPERATIVE  SURGERY. 


a  perineal  band  attached  to  the  head  of  the  bed    (Fig.  61).     Pre- 
vent eversion  of  the  foot,  espeoial'y  in  fractures  of  the  neck,  by  long 

sand  bags  at  the 
si<les  of  the  leg; 
01-  a  long  side 
splint,  padded, 
may  be  used,  hav- 
ing a  transverse 
piece  at  the  foot. 
Eight  weeks  is  the 
usual  time  which 
a  fracture  of  the 
thi^h  in  an  adult 


Fig.  61.1 


ought  to  remain  in  apparatus,  but  the  extension  may  be  lessened 
when  the  bones  seem  firm,  and  passive  motion  should  be  given  to 
the  knee-joint  as  early  as  the  fifth  or  sixth  week  ;  the  amount  of 
shortening  in  adults,  when  overlapping  continues,  ranges  from  one 
fourth  to  one  and  a  half  inches.^ 

The  gypsum  bandage  should  be  employed  only  by  those  familiar 
with  its  use,  and  in  a  position  to  guard  carefully  against  the  dangers 
of  too  great  compression. 

It  is  applied  as  follows:  3  Place  the  patient  with  his  nates  overhanging  one  cor- 
ner of  a  table,  or  with  his  body,  shoulders,  and  head  resting  upon  a  mattress 
elevated  by  blankets  about  one  foot  from  the  table,  but  terminating  about  two 
feet  from  its  lower  end;  press  the  perineum  against  an  iron  stanchion,  firmly 
screwed  upon  the  lower  end  of  the  table,  and  wound  with  heavy  flannel  cloth; 
suspend  tlie  nates  by  a  sling  passed  under  the  small  of  the  back  and  supported 
by  a  wooden  bar  projecting  horizontally  from  the  top  of  the  stanchion  to  some 


point  of  support  of  equal  elevation  beyond  the  head;  attach  compound  pulleys 
to  the  foot,  and  give  the  ana'sthetic;  the  patient  being  fully  under  the  influence 
of  the  ana'slhetic,  make  traction  upon  the  pulleys  until  the  shortening  is  over- 
come and  the  fracture  reduced;  the  direction  of  the  extension  must  be  in  the 

1  G.  Buck.        2  Resolve  of  Am.  Med.  Assoc.         ^  Bellevue  Hospital  Pieports. 


THE  INJURIES   OF  BOXES.  91 

line  of  the  axis  of  the  body;  envelop  the  limb  with  a  dry  bandage,  cotton  bat- 
ting, or  old  blanket,  cut  to  lit,  or  drawers,  and  protect  especially  the  groin  and 
gluteal  fold  from  excoriation;  apply  the  bandages,  saturated  with  plaster,  over 
the  whole  limb,  from  below  upwards,  including  the  pelvis;  occasionally  rein- 
force the  successive  turns  of  the  roller  by  broad  pieces  of  tiannel  or  of  patent 
lint,  dipped  in  the  fluid  plaster;  the  numljer  and  thickness  of  the  successive 
laj'ers  must  be  deterniined  by  the  apparent  necessities  of  the  case,  generally 
four  or  live  layers  of  roller  being  required,  at  least  upon  the  thigh;  the  dressing 
being  completed,  continue  the  extension  lifteen  or  twenty  minutes,  until  the 
plaster  has  become  hard;  on  the  second  or  third  day  after  the  reduction  of  the 
fracture,  the  patient  is  allowed  to  move  about  on  crutches. 

Fracture  of  the  femur  in  children  is  best  treated  as  follows ;!  Pro- 
vide two  lonj^  narrow  side  splints  extending  from  near  the  axillaj 
below  the  feet;  connect  them  by  a  cross  piece  at  the  lower  ends  so 
that  they  are  a  little  more  widely  separated  below  than  above,  to 
render  the  perineum  accessible ;  place  them  upon  each  side  of  the 
body ;  secure  the  leg  of  the  broken  limb  to  the  splint  with  a  roller, 
and  fasten  the  remainder  of  the  limb,  the  opposite  limb,  and  the  body 
to  the  splint  with  broad  and  separate  strips  of  cloth;  the  coaptation 
splint  may  be  made  of  binders'  board;  it  is  of  great  importance  to 
confine  both  limbs,  for  as  long  as  one  is  free  it  is  almost  impossi- 
ble to  secure  any  degree  of  quiet;  the  extended  position  is  nmch  to 
be  preferred  to  the  flexed. 

9.  The  patella  fractured  transversely  is  effectually  retained  in 
position  by  tiie  gypsum  bandage  (Fig.  63).  Envelop  the  limb  from  the 
toes  to  the  groin  with  sheet  cotton  or  nicely  fitting  blanketing;  apply 
the  gypsum  bandage  from  the  toes  to  the  groin,  three  thicknesses; 
when  the  dressing  is  hard,  cut  out  a  large  fenestriim  exposing  the 
patella  and  adjacent  parts;  now 
apply  strips  of  adhesive  plaster 
over  the  lower  fragment,  the 
centre  of  each  resting  on  the 
patella,  and  the  ends  extending 
upward    and    fastening    to    the  ^^^'-  ^^^■ 

splint ;  these  strips  should  overlap  each  other  one  third  from  below 
upwards;  when  the  lower  fragment  is  firmly  fixed,  apply  strips  in  a 
similar  manner  to  the  upper  fragment,  forcing  it  downward:  it  is 
well  to  apply  a  last  plaster  directly  over  the  centre  of  the  patella, 
to  prevent  the  broken  surfaces  from  tilting  upwards. 

The  following  method  l  is  often  adopted:  Elevate  the  limb  upon  a  well-cush- 
ioned inclined  plane,  in  which  is  cut  a  deep  notch  alxtut  four  inches  below  the 
knee;  the  foot-piece  is  at  right  anules  with  the  inclinc<l  plane,  and  not  at  right 
angles  with  the  horizontal  floor;  and  perforated  with  holes  for  the  passage  of 
tapes  or  bandages  to  secure  the  foot.     Having  covered  the  apparatus  with  a 

1    F.  11.  IlAMII.roN- 


92 


OPERA  TI VE  S  UR  GER  Y. 


soft  and  thick  cushion  carefully'  adapted  to  all  the  irregularities  of  the  thigh 
and  leg,  take  especial  care  to  till  the  space  under  the  knee;  lay  the  whole  limb 
upon  it.  and  secure  tiie  foot  gentlj'  to  the  foot-board,  between  which  and  the 
foot  place  another  cushion;  the  body  of  the  patient  should  also  be  flexed  upon 
the  thigh,  so  as  the  more  effectually  to  relax  the  quadriceps  fenioris  muscle. 
Now  place  a  compress  made  of  folded  cotton  cloth,  wide  enough  to  cover 
the  whole  breadth  of  the  knee,  and  long  enough  to  extend  from  a  point  four 
inches  above  the  patella  to  the  tuberosity  of  the  tibia,  and  one  quarter  of  an  inch 
thick,  on  the  front  of  and  above  the  knee.  While  an  as.>;istant  presses  down  the 
upper  fragment  of  the  patella,  secure  it  in  place  with  bands  of  adhesive  plaster; 
each  band  should  be  two  or  two  and  a  half  inches  wide,  and  sufficiently  long 
to  enclose  the  limb  and  splint  obliquely;  la}'  the  centre  of  the  first  band  upon 
the  compress,  partly  above  and  partly  upon  the  upper  fragment,  and  bring  its 
extremities  down  so  as  to  pass  through  the  two  notches  on  the  side  of  the  splint, 
and  close  upon  each  other  underneath;  let  the  second  band,  imbricating  the 
first,  descend  a  little  lower  upon  the  patella,  and  secure  it  below  in  the  same 
manner;  the  third,  and  so  on  successively  until  the  whole  is  covered,  after 
which  apply  a  roller  from  the  foot  to  the  groin. 

The  lei;  should  not  be  fle.xed  freely,  under  three  months.^ 
10.  The  tibia  is  very  little  displaeed,  when  broken  alone,  and  re- 
quires only  a  leather  splint,-  or  a  properly  adjusted  plastic  dressing. 
A  very  neat  and  simple  plastic  dressing  may  be  made  with  flannel, 
plaster  of  Paris,  and  shellac,^  prepared  and  applied  as  follows  : 
After  replacing  the  fragments  as  accurately  as  possible,  extension 
being  maintained  by  assistants,  bandage  the  limb  smooth'y  with  cot- 
ton wadding,  prepared  in  the  form  of  an  ordinary  roller;  now  soak 
a  flannel  bandage  spread  with  dry  plaster  of  Paris  and  rolled,  in 
warm  water,  adding  about  two  fluid-ounces  of  saturated  solution  of 
sulpliate  of  potassium,  and  apply  to  the  limb,  over  the  wadding,  by 
circular  and  reversed  turns;  one  layer  of  the  (iannel  applied  in  this 
way  is  amply  sufficient  for  supjjort;  the  splints  should  be  varnished 
with  shellac.  To  inspect  the  point  of  fracture,  the  dressing,  which 
is  only  about  an  eightli  of  an  inch  thick,  is  easiiy  cut  through. 

To  avoid  die  difficulty  in  removing  plaster  of  Paris  dressings  when  applied  by 
the  roller  bandage  to  the  leg,  the  following  method  of  dressing  is  very  con- 
venient :  3  Take  a  woolen 
or  cotton  stocking  suffi- 
ciently long  to  reach  to 
the  knee-joint,  and  cut 
from  it  as  a  pattern  six 
layers  of  coarse  red  flan- 
nel, one  quarter  of  an 
inch  larger,  to  allow  for 
shrinkage;  soak  the  flan- 
nel in  water,  press  and  lay 
over  the  back  of  a  chair, 
ready  for  use  ;  sew  a  one 
quarter  inch  cotton  rope  to  the  posterior  median  line  of  the  stocking  (Fig.  64); 
1  T.  Brvant.  ^  F.  H.  Hamilton.  3  g.  Wackerhagen. 


Fig.  64. 


THE   IXJiRIKS   OF  BOXES. 


93 


the  plaster  of  Paris  lieiiig  in  process  of  preparation;  cut  the  stocking  in  the  an- 
terior median  line,  apply  it  to  the  fractured  linili,  lace  up  in  front,  including 
the  rope,  extension  and  counter-extension  being  kept  up  by  assistants;  adjust 
the  fracture;  saturate  each  layer  of  the  fiannel  now  separately  in  the  plaster 
paste,  suid  apply  three  layers  to  each  side  of  the  limb,  being  careful  to  avoid 
covering  the  ri)i)e;  after  this  is  done,  apply  a  layer  of  planter  paste  to  the  flan- 
nel, and,  when  tliis  has  become  sulHciently  dry,  a  coating  of  shellac  varnish, 
which  produces  an  elegant  finish,  and  also  gives  lirmncss  to  the  splints;  the 
varnish  will  dry  in  about  lifteen  minutes.  Remove  by  loosening  the  rope  from 
the  plaster  and  cutting  tlie  thread  which  binds  it  to  the  stocking;  cut  the  plain 
Stocking  surface  with  an  ordinary  pair  of  scissors. 

11.  The  fibula  is  most  frequently  fractured  two  or  three  inches 
al)()ve  the  lower  end ;  the  most  convenient  dressing  is  the  o;yj)sum, 
which  must  include  the  foot,  except  the  toes;  the  fracture  must  he 
reduced  and  the  foot  held  firmly  in  position  until  the  limb  is  dressed 
and  the  material  has  har<leiu'd. 


A  usefid  dressing,  frequently  applied,  is  constructed  as  follows  (Fig.  C.5):i  Se- 
lect a  board,  abcnit  four  inches  wide^ 
of  sullicient  length  to  e.xtend  from 
the  condyle  of  the  fennu-  to  two  or 
three  inches  beyond  the  foot;  upon 
this  place  a  long  triangular  pad,  the 
thickest  portion  of  the  triangle  cor- 
responding to  a  point  about  an  inch  above  the  internal  malleolus  ;  the  splint, 
with  the  pad  resting  upon  it,  lying  along  the  inside  of  the  leg,  is  secured  by 
roller  bandage,  which  must  not  cover  the  site  of  the  fracture. 

12.  The  tibia  and  fibula  are  usually  fractured  in  the  lower  third. 
Apply  a  gypsum  dressini;-  made  as  follows  :  Select  two  pieces  of 
flannel,  suited  to  the  lenijth  and  circumference  of  the  limb,  and 
cut  them  so  as  to  overlap  slightly  in  front,  when  they  resemble  the 
leg  of  a  stocking  opened  vertically;  lay  one  over  the  other,  and 
stitch  them  together  from  top 
to  bottom  down  the  middle  line, 
like  two  pieces  of  note  paper 
stitched  at  the  fold;  spread 
them  out  under  the  limb  so 
that  the  line  of  stitching  corre- 
sponds to  the  back  of  the  calf ; 
bring  the  two  inner  folds  to- 
gether, over  the  shin  CFig.  GO), 
and  fasten  them  by  long  pins  or  by  stitches ;  while  the  leg  is  held  firm- 
ly in  position,  mix  the  plaster  with  about  an  equal  bulk  of  water,  and 
rapidly  apply  it,  partly  with  a  spoon  and  partly  by  pouring  it  over  the 
outer  surface  of  flannel  covering  the  limb;  quickly  bring  the  two  por- 

1  Dupuytren.  -  Bavarian. 


Fig.  G6. 


94  OPERATIVE  SURGERY. 

tions  of  the  second  layer  over  so  as  to  meet,  and  smooth  them  with 
the  hand,  so  as  to  remove  the  inequalities  in  the  distribution  of  the 
plaster  before  it  hardens;  the  gypsum  sets  in  about  three  minutes, 
incasing  the  limb  in  a  strong,  rigid  covering.  To  take  the  dressing 
off,  open  it  like  the  leaves  of  a  book;  its  edges  must  be  trinmied,  and 
the  pins  removed;  maintain  it  in  position  afterwards  by  straps  with 
buckles  or  a  very  firm  bandage.  This  fracture  may  also  be  treated 
by  leather  splints,  one  on  either  side,  extending  from  above  the 
knee  to  near  the  tarso-phalangeal  articulations.  The  apparatus 
must  more  or  less  completely  envelop  the  limb.  Sole  leather  cut 
so  as  nearly  to  inclose  the  limb,  then  softened  in  warm  water  and 
moulded  to  the  leg,  makes  a  firm  dressing  when  it  becomes  dry. 

A  verj'  shnple  gypsum  splint  may  be  made  and  applied  as  follows : '  Select  a 
piece  of  house-flannel  or  an  old,  thin,  shrunk  blanket,  or  any  suitable  substitute; 
shape  the  pieces  by  measurement,  taking  the  circumference  of  the  limb  below 
the  knee,  at  the  biggest  part  of  the  calf,  just  above  the  ankle-joint,  from  the 
front  of  the  ankle-joint  round  the  heel  to  the  front  again,  and  at  the  middle  of 
the  metatarsus;  the  flannel  of  each  splint  should  be  in  width  half  an  inch  less 
than  half  the  circumference  at  any  of  those  points;  the  width  of  the  two  splints 
should  be  one  inch  less  than  the  circumference  of  the  limb  at  any  correspond- 
ing part,  and  long  enough  to  extend  from  the  tubercle  of  the  tibia  to  the 
middle  of  the  metatarsus;  four  pieces  are  required,  two  for  each  splint;  pre- 
pare two  bandages  of  common  muslin,  each  five  to  six  yards  long  and  two 
inches  and  a  half  in  width;  mix  about  a  handfid  of  good  dry  plaster  with  water 
to  the  consistence  of  thick  cream;  lay  the  inside  pieces  of  flannel  on  the  table 
or  bed,  the  outer  surface  being  upwards;  soak  tiie  outside  pieces  in  the  plaster 
separately,  and  lay  them  out  on  their  respective  inside  pieces.  Whilst  traction 
is  kept  up,  and  the  ends  of  the  broken  bones  are  maintained  in  apposition,  the 
splints  are  to  be  applied  and  smoothed;  then  the  bandage  is  to  be  put  on  ;  trac- 
tion is  to  be  maintained  during  the  hardening  of  the  plaster;  next  the  limb 
should  be  laid  on  a  large  soft  pillow,  the  toes  directed  upwards,  and  the  knee  a 
little  bent;  in  the  application  of  the  bandage  great  caution  siiould  be  observed 
that  it  is  not  drawn  tightly  anywhere,  and  that  no  one  turn  of  the  bandage  is 
tighter  than  another;  the  two  splints  should  not  meet  by  about  half  an  inch 
either  down  the  front  or  back;  the  intervals  are  spanned  by  the  dry,  porous 
muslin;  at  the  sides  the  bandage  is  fixed  to  the  splints  by  the  plaster,  which 
oozes  into  it  from  the  outer  layer  of  flannel;  if  it  becomes  necessary  next  daj', 
or  later,  to  ease  the  splints,  or  to  inspect  the  limb  at  anv  spot,  the  bandage  can 
be  slit  up  with  scissors  along  the  middle  line  in  front.  They  are  hinged  to- 
gether at  the  back  by  the  muslin  bandage  which  spans  the  interval  there. 
These  splints  are  characterized  by  their  simplicity,  stal)ility,  and  economy, 
and  therefore  commend  themselves  strongly  to  the  countrv  practitioner;  the 
surgeon  can  take  out  with  him,  to  his  case,  a  bag  of  plaster  of  Paris,  and  the 
muslin  bandages,  and  perhaps  the  flannel;  the  plaster  should  be  good,  but 
need  not  be  the  very  best;  must  be  dry,  and  should  be  kept,  when  in  store,  in 
a  dry,  warm  place;  be  cautious  in  using  an\'  flannel  which  has  not  been  in 
some  way  shrunk. 

1  J.  Croft. 


THE  INJURIES  OF  BOXES.  95 

II.     COMPOUND  FRACTURES. 

A  fracture  is  compound  when  it  comnuinicates  through  a  wound 
with  the  external  air.  These  injuries  have  always  been  regarded  as 
dangerous  because  such  wounds  commonly  inflame  and  suj)purate,' 
but  when  they  are  protected  from  the  action  of  septic  ferments  re- 
covery will  occur  with  slight  inflammation  and  suppuration.  The 
first  question  to  determine  is  as  to  the  possibility  of  saving  the  limb» 
and  as  a  rule,  the  attempt  should  be  made  if  the  injury  to  the  soft 
parts  is  not  very  great;  if  the  bone  does  not  largely  protrude,  and  the 
skin  is  not  extensively  lacerated;  if  the  continued  warmth  of  the 
limb  below  the  fracture  indicate  the  escape  of  the  main  artery,  and 
that  the  nerves  are  not  implicated. ^  The  thorough  use  of  disin- 
fectants, by  which  putrefactive  suppuration  is  now  prevented,  adds 
largely  to  our  means  of  saving  limbs  after  compound  fractures. 

The  first  indication  is  to  convert  the  compound  into  a  simple 
fracture  when  the  opening  is  very  slight  and  readily  closed;  this 
may  be  done  with  collodion,  or  with  any  dressing  which  hermetically 
seals  the  wound.  If  the  bone  protrude,  attempt  reduction  by  ex- 
tension and  counter-extension;  if  this  fail,  introduce  the  finger  or 
the  spatula  into  the  wound  and  endeavor  to  stretch  the  skin  over 
the  sharp  point  of  bone;  if  all  efforts  fail,  enlarge  the  wound  suffi- 
ciently to  insure  return;  if  the  bone  is  denuded  or  very  sharp,  saw  off 
the  projecting  end;  ligate  ruptured  arteries  which  can  be  readily 
found.  Anaesthetics  may  be  useful  during  these  efforts.^  If  the  case 
is  seen  at  once,  cleanse  the  wound,  disinfect  every  portion  liable  to 
contain  septic  ferments,  secure  perfect  rest,  and  prevent  the  entrance 
of  any  poisons.  Employ  the  antiseptic  dressing,  which  best  meets 
these  indications,^  as  follows:  Use  the  spray  during  the  dressing; 
if  the  contusion  is  slight,  inject  carbolic  solution,  1  to  20,  into  the 
wound,  and  apply  the  gauze;  if  there  is  much  contusion,  enlarge  the 
wound  an<l  inject  the  same  solution  freely  and  forcibly  among  the 
injure<l  tissues,  and  dress  as  before;  repeat  the  injection  at  every 
dressing  when  the  discharge  is  offensive,  opening  the  wound  more 
freely,  if  necessary,  to  reach  deeper  recesses.  If  the  suppuration 
has  extended  very  deeply,  and  is  offensive,  the  wound  must  be  still 
more  freely  enlarged,  and  a  solution  of  carbolic  .acid  in  wine,  1  to  5, 
injected,  and  if  necessary  through  a  tube  introduced  to  the  most  re- 
mote recess.*  If  the  gauze  is  not  at  hand  at  each  dressing,  after 
thoroughly  disinfecting  all  ])arts  of  the  wound  with  the  carbolic  so- 
lution, fill  the  cavities  and  the  entire  open  spaces  with  pled'^ets  of 
lint  saturated  with  carbolized  oil. 

The  plastic  dressing  should  next  be  applied  ;  if  there  is  danger  of 

1  J.  Hunter.  2  p.  c.  Skey.  8  F.  H.  Hamilton.  *  J.  Lister. 


96 


OPERATIVE  SURGERY. 


too  much  swelling,  it  may  be  applied  only  to  the  under  and  lateral 
surfaces,  leaving  the  upper  and  injured  surface  free  (Fig.  67).     As 

early  as  possible,  how- 
ever, the  gypsum  dress- 
ing should  be  so  applied 
as  to  completely  envelop 
the  limb,  a  protective 
being  ])laced  next  to  the 
skin,  as  cotton  batting, 
or  thick  flannel;  when 
completed  and  nearly 
diy,  a  fenestrum,  or  if  necessary  two  or  three,  should  be  cut  out 
so  as  to  give  full  access  to  the  wound  (Fig.  68);  the  limb  is  then 
suspended. 


Fig.  67. 


III.     SHOT  FRACTURES. 

Projectiles^  cause  a  variety  of  partial  and  complete  fractures;  the 
former  are  (1)  removal  of  a  portion  of  bone,  (2)  splintering  off  of 

fragments  of  the  exter- 
nal cylindrical  part  of 
a  bone,  (3)  making  a 
hole  throughout  the  en- 
tire substance  of  the 
bone,  (4)  driving  the 
external  cylinder  into 
the  cancellated  struc- 
iK,.  ii8.  ture;  the  latter  are  (1) 

simple  when  the  injury  is  indirect,  and  (2)  compound  when  the  pro- 
jectile is  brought  in  direct  contact  with  the  injured  bone.  These 
fractures  are  always  serious  injuries,  as  they  frequently  involve  the 
question  of  resection  and  amputation,  and  are  always  liable  to  dan- 
gerous complications,  as  haemorrhage,  tetanus,  septicaemia,  and  py- 
aemia. The  course  of  treatment  indicated  varies  with  the  bone 
fractured,  and  the  nature  and  extent  of  the  injury. 

1.  The  superior  maxilla  has  such  relations  to  the  structure  of 
the  face  tlmt  every  effort  shoidd  be  made  to  preserve  its  symmetry 
when  broken  by  shot  injuries.  Unless  the  fragments  are  cither 
completely  detached  or  but  slightly  adherent,  they  should  not  lie 
taken  away,  but  be  replaced  with  care,  as  in  time  consolidation  may 
take  place,  and  very  little  permanent  deformity  be  left ;  after  care- 
ful adjustment  of  the  movable  fragments,  close  the  wound  with  ad- 
hesive plaster,  and  apply  cold-water  dressings ;  if  fragments  subse- 


1  T.  Longmore. 


THE  INJURIES   OF  BONES.  97 

quently   loosen,    roinove    tlicm.^      Bony   union    of   these    fragments 
usually  takes  place  with  <j;reat  facility.'^ 

2.  The  inferior  maxilla,  fractured  by  projectiles,  is  with  ilifTiculty 
retained  in  position;  the  fragments  should  be  preserved  atnl  adjusted, 
and  efforts  made  to  retain  them  in  apposition  by  the  four-tailed 
bandage,  with  pasteboard  cap  for  the  jaw,  and  interdental  splints  of 
gutta-pcrcliu.''^ 

3.  The  clavicle  is  in  such  relations  with  the  pleural  cavity  and 
the  larger  vessels  of  the  neck  that  serious  complications  frerpiently 
attend  shot  fractures  of  that  bone.  In  the  treatment  of  uncompli- 
cated fractures,  remove  detached  splinters  immediately,  and  necrosed 
fragments  at  the  earliest  practicable  moment;*  then  leave  the  injury 
to  nature,  with  as  little  operative  interference  as  possible,  for  the 
less  the  wound  and  bones  are  manipulated  the  better  the  result.* 

4.  The  humerus  should  always  be  subjected  to  conservative  treat- 
ment, unless  extremely  injured  by  a  massive  projectile,  or  longitu- 
dinal comminution  exist  to  a  great  extent,  or  a  joint  is  also  involved, 
or,  finally,  the  patient's  health  is  unfavorable.^  In  cases  which  ad- 
mit of  conservative  treatment,  proceed  as  follows  :  If  tlie  bone  is 
much  splintered,  extend  the  wound  if  necessary  for  exploitation  and 
operation,  at  the  most  depending  opening  if  there  are  two  wounds, 
or  make  a  fresh  incision  if  only  one  exists  and  it  is  not  in  a  favor- 
able position;  make  an  examination  with  the  finger  for  any  foreign 
bodies  or  detached  pieces  of  bone,  and  remove  thein;  remove  also 
such  partially  detached  portions  and  fragments  as  are  retained  only 
by  very  slight  and  narrow  periosteal  connections,  and  saw  or  cut  off 
sharp  points  of  projecting  spicula.^  Dress  the  wound  with  lint 
soaked  in  carbolized  oil,  and  support  the  limb  by  a  fenestrated  splint 
of  gypsum,  or  sole  leather,  or  other  material  capable  of  being 
muuliled  to  it,  and  which  will  secure  rest.  Immobility  is  securely 
obtained  by  a  triangular  cushion"  and  axillary  pad  interposed  be- 
tween the  thorax  and  the  arm  (Fig.  GO). 

This  useful  appliance  consists  of  a  three-cornered  cushion,  with  rounded 
edges,  made  of  horse-hair,  upholstered  with  soft  material,  and  inclosed  with 
waterproof  material.  It  is  applied  as  follows  :  One  of  the  rounded  edfjes  is 
placed  in  the  axilla,  and  is  then  fixed  by  a  bandatje,  attached  behind  and  in 
front  by  safety-neeflles,  and  passed  over  the  opposite  or  healthy  shoulder;  the 
fractured  arm  is  then  laid  upon  the  cushion,  and  both  are  maintained  in  position 
by  a  broad  sling;  the  woun<l  is  now  dressed  with  a  Scultetus'  bandage,  the 
edges  of  the  sling  being  drawn  back  for  that  purpose. 

5.  The  radius  and  ulna,  like  the  humerus,  should  be  conserva- 
tively treated  ui\less  there  is  partial  ablation  by  a  cannon  ball,  or 
comminution  of  both  bones  with   Incei-ation  of  the  blood-vessels  and 

>  J.  J.  Chisholm.       -  F.  II.  Hamilton.  3  G.  A.  Otis.         <  B.  Beck. 

6  T.  Longmore.         "^  F.  Stromeyer. 
7 


98 


OPERATIVE  SURGERY. 


nerves,  or  extensive  comminution  in  the  vicinity  of  joints,  with  fis- 
sures extending  into  the  articulations.*     After  extractino;  loose  frajr- 


FiG.  69.2 
ments,  if  no  considerable  dcfornuty  exists,  only  simple  splints  and 
bandages  are  required;  if  there  is  great  tendency  to  displacement, 
the  fenestrated  g}'psum  dressing,  applied  when  the  arm  is  midway 
between  pronation   and   supination,   with  a  slightly  bent  elbow,  is 

most  useful.^  If  but  a 
single  bone  is  fractured, 
the  most  simple  splint 
dressing  is  required. 

Suspension  of  the  fore-arm 
in  the  early  stages  of  treat- 
ment is  very  important,  and 
mav  be  effected  by  simple 
apparatus,  as  follows  (Fig. 
70):*  Select  iron  tubing, 
or  other  material,  fasten  its 
upright  portion  by  clamps 
at  the  head  of  the  bedstead, 
while  its  lower  portion  over- 
hangs the  bed  and  holds  sus- 
pended at  its  extremity  a 
flattened  strip  of  hard  wood, 
on  the  upper  edge  of  which 
a  row  of  screw  heads  serves 
for  fastening  the  ends  of  the 
canvas  bands  that  suspend 
the  limb;  the  strip  of  wood 

that  supports  the  limb  should  play  horizontally  on  a  swivel  joint  at  the  e.Ktrem- 

ity  of  the  iron  tubing. 

6.  The  metacarpal   and   phalangeal  bones    should,  as  far  as 

.practicable,  be  preserved,  wdiatever  the  nature  of  the  injury,  though 

their  functions  may  subsequently  be  greatly  limited.     Their  wounds 
1  F.  Schwartz.  2  F.  Esmarch.  3  H.  Fischer.  <  G.  Buck. 


Fig.  70. 


THE  INJURIES   OF  BONES. 


99 


are  extremely  painful  and  troublesome  in  manaf^ement,  but  are  not 
specially  liable  to  induce  tetanus.^  In  the  treatment,  splinters  and 
foreign  bodies  should  first  be  removed;  free  incisions'  through  the 
aponeurotic  layers  are  important  in  preventing  accumnlations  of 
matter  under  fasciaj  and  tendons,  or  relieving  tension  caused  by  such 
collections.  Carljolized  oil  ilressings  j)ressed  into  the  wounds  in  or- 
dinary cases,  and  the  hot  water  in  those  liable  to  extensive  sloughs, 
should  be  early  resorted  to  and  persistently  used;  the  hand  may  be 
8uj)ported  upon  ])r()perly  adapted  splints. 

7.  The  femur,-  fractured  by  a  modern  rifle-ball,  is  generally  exten- 
sively comminuted,  and  often  fissured  for  long  distances  along  the 
shaft;  an  attempt  to  conserve  the  injured  limb,  however  free  from 
complications,  and  however  favorable  the  case  may  appear  to  be, 
will  unavoiilably  subject  the  patient  to  a  wide  variety  of  hazardous 
circumstances,  owing  to  the  prolonged  treatment  and  attendant  dilR- 
culties  which  must  necessarily  occur  before  a  cure  can  be  completed. 
If  the  femoral  artery  and  vein  have  been  divided,  any  attempt  to 
save  the  limb  will  certainly  prove  fatal.  In  shot  fractures  of  the 
upper  third  of  the  femur,  especially  if  it  be  doubtful  whether  the 
hip-joint  is  implicated  or  not,  the  question  is  still  open  whether  ex- 
cision of  the  injured  portion,  or  removal  of  the  detached  fragments 
and  relying  on  the  natural  efforts  for  union,  or  amputation,  which  is 
very  dangerous,  is  best  for  the  safety  of  the  patient.  The  decision 
must  depend  upon  the  extent  of  the  injury  to  the  surrounding  struc- 
tures, the  condition  of  the  patient,  and  other  circumstances  in  each 
individual  case.  As  a  general  rule,  in  fractures  in  the  middle  and 
lower  third  of  the  thigh,  amputation  is  held  to  be  a  necessary  meas- 
ure. When  it  is  deter- 
mined to  attempt  to  save 
the  limb,  the  wound  may 
be  enlarged  to  remove 
spicula  of  bone,  and  oc- 
casionally counter  open- 
ings should  be  made  to 
prevent  the  accumula- 
tions and  burrowing  of 
Fig.  71.  pus;    carbolic    solutions 

should  be  injected  into  all  the  recesses,  and  carbolized  oil  on  lint 
be  introduced  with  forceps  to  avoid  creating  additional  irritation ; 
cold  water  or  ice  dressings  may  at  first  be  applied,  to  be  discon- 
tinued if  suppuration  occurs.  The  part  should  finally  be  perfectly 
immobilized  by  ap])aratus;  for  this  purpose  the  splint  should  allow 
the  limb  to  be  swung  so  as  to  admit  of  dressing  without  change  of 
1  G.  A.  Otis.  2  T.  Longmore. 


100 


OPERATIVE  SURGERY 


Fig.  72. 


position.  The  gypsum  splints  or  the  fenestrated  gypsum  bandage 
may  be  employed  (Fig.  71),  or  the  cradle  with  a  light  weight  at  the 
foot  (Fig.  73).     A  wire  suspending  apparatus  ^  (Fig.  72)  has  given 

good  results:  — 

Tlie  frame  is  stout  wire;  strips  of  cloth  are 
laid  across  the  splint  from  side  to  side,  and 
upon  these  the  limb  is  laid;  the  centre  and 
upper  extremity  of  the  splint  are  kept  asun- 
der by  strong  bows  of  iron  wire,  so  arranged 
that  they  can  be  put  on  or  taken  off  with- 
out disturbing  the  dressings;  when  applied, 
the  inside  wire  must  be  bent  upwards  at  its 
upper  extremity,  so  as  to  make  room  for 
the  pubes;  extension  is  made  bj'  adhesive 
4\  plasters,  and  the  whole  apparatus  is  finally 
suspended  to  the  ceiling  or  to  some  point 
above  by  a  rope  or  pulley. 

8.  The  tibia  and  fibula,  fractured 
without  implication  of  the  knee  or  ankle  joints,  are  very  amenable  to 

conservative  measui-es,  and 
hence,  as  a  general  rule,  or- 
dinary fractures  below  the 
knee,  fi'om  rifle  balls,  should 
never  cause  primary  am- 
putation. ^  The  treatment 
should  consist  in  freeing  the 
wound  of  all  foreign  matters 
and  splinters,  the  local  use 
of  carbolized  oil  on  lint,  and 
Fig.  73.  tlie  application  of  the  gyp- 

sum splint  noticed  in  the  treatment  of  ordinary  compound  fractures 
in  this  region. 

A  very  simple  apparatus*  may  be  made,  consisting  of  a  wooden  frame 
formed  of  four  square  bars  of  the  length  of  the  lower  extremity,  two  on  either 
side  of  the  leg,  united  by  a  crescent-shaped  piece  of  wood  situated  at  the  back 
of  the  knee,  and  by  a  foot-board  below;  the  lower  two  serve  the  purpose  of  hold- 
ing the  apparatus  together,  and  making  an  inclined  plane;  the  upper  bars  serve 
as  points  of  attachment  for  a  number  of  linen  straps  or  rollers  to  suspend  the  limb, 
which  pass  from  side  to  side  and  are  fastened  with  pins;  they  constitute  a  per- 
fect bed,  having  the  advantage  of  adapting  themselves  to  the  differences  in  the 
conformation  of  the  limb;  the  foot  is  retained  to  the  foot-board  by  long  adhesive 
plaster  strips,  passed  around  the  foot-board  and  carried  upwards  and  secured 
to  both  sides  of  the  leg  with  roller  bandage,  leaving  a  sort  of  loop  beneath  the 
foot-board,  through  which  a  rope  is  passed  and  attached  to  a  little  l)ag  weighted 
with  sand,  for  the  purpose  of  keeping  up  extension;  counter-extension  is  made 
by  a  perineal  band,  the  end  of  which  is  secured  to  the  head  of  tiie  bed;  a  long 
cross-bar  under  the  foot-board,  resting  on  the  bed,  prevents  the  apparatus  from 


1  J.  T.  Hodgen. 


2  T.  Longniore. 


3  G.  Tiemann  &  Co. 


THE  DISEASES   OF  BOXES.  101 

tilting;  bricks  may  be  placed  under  the  legs  of  tlie  bed  at  tlie  foot,  to  give  the 
apparatus  an  incliiiatiun  towards  flie  pelvis;  one  of  the  advantages  of  this  in- 
strument is  that  each  of  the  bands  of  linen  may  be  removed  separately,  any 
wound  dressed,  and  the  band  reapplied  without  displacing  the  others. 


CHAPTER  XIII. 

DISEASES   OF  BONE  AND   SPECIAL   OPERATIONS. 

Morbid  anatomy  illustrates  physiological  processes  very  mark- 
edly in  the  osseous  system;  in  every  case  some  analogy  at  least  may 
be  discovered  between  the  morbid  phenomena  and  a  normal  proto- 
type; in  many  cases  there  is  a  simple  excess  or  deficiency  of  normal 
growth,  but  in  the  larger  niunber  there  is  a  predominant  activity 
of  single  anatomical  factors  whose  part  in  normal  growth  is  more 
subordinate.^  In  the  examination  as  to  the  condition  of  bone, 
much  useful  information  may  be  obtained  in  obscure  cases,  both  as 
to  the  seat  and  nature  of  the  disease,  by  percussion ; '^  the  instrument 
used  should  be  a  metallic  hammer  with  a  whalebone  handle,  and  the 
bone  should  be  firmly  compressed  on  two  sides;  of  the  more  notice- 
able sounds  elicited  by  percussion  of  diseased  bone  are  a  high  pitch 
when  the  bone  is  very  compact,  as  in  osteo-sclerosis,  and  a  hollow 
sound  when  the  bone  is  very  porous,  as  in  osteo-porosis. 

I.  RICKETS. 
The  swellings  and  distortions  of  rickets  depend  on  a  morbid  ac- 
celeration of  those  changes  which  usher  in  and  prepare  the  way  for 
the  transformation  of  cartilage  into  bone,  and  the  development  of 
bone  from  periosteum;  ossification  follows  at  a  slower  pace,  and  hence 
the  substance  which  should  undergo  immediate  conversion  into  bone- 
tissue  accumulates,  forms  swellings,  and  allows  the  bones  to  be  bent 
and  broken. 1 

In  its  various  forms  rickets  ^  is  a  very  common  affection  in  children  from  six 
months  to  two  years  of  age,  who  live  in  damp,  dark,  ill-ventilated  apartments 
and  have  insufficient  or  improper  food.  Faulty  digestion  results  in  the  de- 
velopment of  acids,  mainly  lactic,  in  the  blood,  and  the  rapid  elimination  of  the 
phosphates  by  the  kidneys.  The  child  grows  feeble,  peevish,  nielancholv.  has 
perspiration  of  the  head;  the  ends  of  the  long  bones,  radius,  tibia,  and  ribs, 
enlarge,  and  those  bones  subjected  to  pressure  bend. 

The  general  treatment  is  (1)  fresh  air  and  sunlight;  (2)  cod-livor 
oil,  and  syrup  of  iodide  of  iron,  or  the  compound  syrup  of  the  phos- 
phates.    The  mechanical  treatment  consists  in  supporting  the  bones 

1  E.  Rindfleisch.  2  a.  Liicke.  3  j.  L.  .Smith. 


102 


OPERATIVE  SURGERY. 


which  are  inclined  to  curve  during  the  period  of  softening  ;  the  great- 
est care  and  discretion  are  required  to  avoid  doing  harm  by  undue 
pressure  on  yielding  bones;  as  far  as  possible  the  weight  of  the  body 
should  be  taken  from  the  long  bones,  and  when  curvature  occurs 
gentle  lateral  support  shoukl  be  given  by  well- 
padded  splints,  making  such  points  of  pressure 
as  will  not  involve  other  bones.  Plastic  appara- 
tus may  be  applied  to  support  a  weak  spinal 
column  and  the  lower  extremities.  The  curva- 
ture of  the  lower  limbs  maj'  be  very  firmly  sup- 
ported by  apparatus  which  protects  the  bones 
without  other  pressure.  If  curvature  exists, 
-c  much  may  be  accom])lished  in  straightening  the 
limb  of  the  child  that  does  not  walk,  by  firm 
pressure  and  extension  with  the  hands,  repeated 
several  times  daily.  When  the  child  is  walking 
an  apparatus  may  be  adjusted  to  the  tibia.    (Fig. 

Fig.  74.  ^'^"^ 

Two  upright  steel  stems  are  fastened  below  to  a  shoe  and  terminated  above 
in  the  calf-band;  a  leather  bandage  is  passed  around  the  stems  and  tightly  laced 
in  front  over  the  arc  of  the  curvature  {a),  or  a  strap  is  passed  over  t'le  arc  of 
the  curvature  and  fastened  to  a  spur  suspended  from  the  calf-band  behind 
(c)  ;  the  points  of  resistance  being  in  either  case  the  heel  of  the  shoe  (6)  and 
the  posterior  trough  of  the  calf-band  (c). 

When  the  bones  of  the  leg  and  thigh  are  both  bent,  the  apparatus 
must  be  so  constructed  as  to  overcome  the  deformity  which  takes 
different  directions. 

The  support  is  given  by  double  stems  of  steel,  secured  to  a  shoe,  carried  up  as 
high  as  the  thigh  and  jointed  at  the  ankle  and  knee  to  allow  the  patient  perfect 
freedom  of  motion;  they  are  kept  in  place  by  calf  and  thigh  bauds.  The  bow 
is  corrected  by  pads  being  placed  respectively  against  the  ankle  and  knee  on  the 
concave  side  of  the  limb,  whilst  a  strap  passed  around  on  the  highest  point 
of  the  arc,  inside  of  the  outer  stem,  tightly  buttoned  to  the  steel  bar  on  the  con- 
cave side,  gradually  compels  the  leg  to  become  parallel  with  it;  in  slight  cases, 
or  when  the  bow  is  greatest  below  the  calf,  an  instrument  carried  up  to  the  knee 
is  sufficient. 

When  the  bones  have  become  consoliilated  in  deformed  positions 
which  impair  function,  they  must  be  straightened  by  osteoclasis  or 
osteotomy. 

ir.  TUMORS   OF  BONE. 

Osseous  tumors  are  distinguished  from  other  ossifying  tumors  by 
the  uniform  production  of  true  "bone  as  an  essential  element  in  their 
development.  1  They  are  never  formed  altogether  of  bone,  but  there  is 
always  present  an  ossifying  matrix,  derived  generally  from  the  perios- 

1  R.  Virchow. 


THE  DISEASES   OF  BONE.  103 

tcuin  and  cartihujc;  the  amount  of  periosteum,  eartilage,  and  bone 
present  varies  indefinitely  in  different  cases.  *  In  the  diagnosis, ^  gen- 
eral smoothness  of  surface  is  usually  significant  of  a  tumor  growing 
witliin  a  bone  and  expanding  it,  unless  in  the  case  of  cartilaginous 
tumors,  which,  after  growing  within  bones,  have  protruded  through 
some  of  their  expanded  walls;  pulsation  in  a  non-cancerous  tumor 
connected  with  bone  is  a  nearly  certain  sign  of  growth  within  bone, 
exce|)t  in  the  case  of  luyeloiii  ej)ulis;  if  these  means  of  diagnosis 
are  insuflicient,  resort  to  puncture  or  an  exploratory  incision.  In 
operations  for  the  removal  of  tumors  of  bone,  the  following  general 
rules'^  should  be  borne  in  mind  :  (1)  Simply  removing  a  tumor  from 
the  place  in  which  it  lies  is  as  sufficient  for  tlie  cure  of  one  growing 
in  a  bone  as  for  tliat  of  one  growing  in  connective  tissue  ;  (2)  it  is 
rarely  necessary  to  disturb  the  continuity  of  a  bone  in  order  to  re- 
move from  it  any  innocent  tumor;  (3)  the  safety  of  removing  a 
tumor  from  within  a  bone  is  greater  than  that  of  any  resection  or 
amputation  that  might  have  been  performed  as  an  alternative  opera- 
tion; (4)  innocent  tumors  growing  on  bones  slionld  be  removed  by 
excision,  and  growing  in  bones  iiy  enucleation ;  (fj)  cancerous  and 
recurrent  tumors  should  generally  be  removed  by  amputation  or  wide 
excision. 

1.  Chondromata,  cartilage  tumors,  are  usually  seated  in  the 
bones;  the  phalanges  of  tlie  fingers  and  toes  are  more  often  af- 
fected; next,  the  humerus,  femur,  and  tibia;  next,  the  jaws,  pelvic 
bones,  and  scapula;  they  may  spring  from  the  periosteum  and  from 
the  medulla;  new  bone  may  form,  layer  after  layer,  producing  a  bony 
capsule  which  may  continue  for  a  long  time.^  They  are  of  slow 
growth,  painless,  rounded,  nodular,  and  when  very  large  prone  to 
ulcerate.  The  treatment  is  removal  when  life  is  not  endangered  by 
the  operation.  Enucleation  ^  is  a  method  to  be  oreferred  when  it 
can  be  effected,  as  in  the  bones  of  the  hand,  the  elastic  bandage 
being  first  applied  to  the  liml);  amputation  is  necessary  wlien  the 
growths  are  multi[)le  or  very  large,  or  when  the  limb  would  be  use- 
less after  their  removal;'*  if  the  tumor  is  in  the  femur,  disarticulation 
is  ad\  isnlilf.^ 

2.  Exostoses  are  manifestations  of  an  increased  jihysiologicnl 
activity  of  the  periosteum  ;  in  the  majority  of  cases  some  general 
disease,  as  syphilis,  rheinnatism,  or  rickets,  has  a  part  in  their 
causation,  though  an  injury  is  often  the  assigned  cause. ^  They 
frequently  occur  in  the  nuiltiple  or  diffuse  form.  They  may  con- 
sist of  (1)  spongy  bone-substance,  which  occurs  almost  exclusively 
on  the  epiphyses  of  the  long  bones,  outgrowths  from  the  epiphyseal 

1  R.  Moxnn.  2  Sir  J.  Paget.  3  e.  KiiulHeisch.  ^  T.  Holmes. 

6  T.  Billroth. 


104  OPERATIVE  SURGERY. 

cartilages,  but  from  the  first  being  intimately  connected  with  the 
spongy  substance  of  the  epiphyses;  (2)  compact  bony  substance, 
ivory-like,  which  develops  on  tlie  bones  of  the  face,  skull,  pelvis, 
scapula,  great  toe;  (3)  ossification  of  tendons,  fascia,  and  muscles, 
where  they  are  attached  to  bone.  These  tumors  form  withou:  pain, 
and  are  inconvenient  when  in  the  vicinity  of  joints  or  on  the  toe, 
and  unsightly  when  on  the  face  or  head.  The  only  treatment  is  ex- 
cision, which  is  neither  advisable  nor  necessary,  unless  the  impair- 
ment of  function  be  so  great  as  to  balance  an  operation  dangerous 
to  the  joint  and  to  life,  for  these  tumors  in  time  cease  to  grow.  On 
epiphyseal  exostoses  mucous  bursa3  are  often  found,  usually  com- 
municating with  the  joint,  which  are  liable  to  be  opened  and  lead  to 
unfortunate  results.^  These  gi'ovvths  do  not  return  when  removed.^ 
When  they  appear  on  the  great  toe  the  phalanx  should  be  ampu- 
tated. The  ivory  exostoses  of  the  skull  owing  to  their  hardness 
are  generally  excised  with  extreme  difficulty  by  means  of  saw  and 
chisel,  and  the  violence  involves  very  great  danger.  As  they  may 
exist  without  other  inconvenience  than  the  deformity  whicli  they 
cause,  the  risk  of  excision  should  not  be  lightly  incurred.  An  ex- 
ception must  be  made  in  the  case  of  ivory  exostoses  of  the  orbit,  as 
the  gradual  growth  of  such  tumors  displaces  the  eye,  causing  blind- 
ness, by  stretching  the  optic  nerve,  and  a  hideous  squint;  the  base, 
usually  attached  to  the  inner  or  outer  angle  of  the  root  of  the  orbit, 
is  often  small,  and  when  fully  exposed  can  be  partially  cut  with  a 
fine  saw,  and  then  bi'oken  with  the  chisel  and  mallet.^  Exostoses  of 
the  antrum  often  have  very  small  bases  and  are  removed  without 
difficulty  on  opening  the  front  wall  of  the  cavity. 

3.  Sarcomata  comprise  two  groups,  namely,  the  external  and 
the  internal,  the  former  springing  from  the  periosteum  and  the 
latter  from  the  medulla.  The  periosteal  growths  embrace  for  the 
most  part  the  hard  forms,  namely,  the  fibro,  chondro,  and  osteoid  sar- 
comata; they  take  their  origin  from  the  layer  of  the  periosteum  next 
to  the  bone,  while  the  external  layer  often  remains  as  a  fibrous  in- 
vestment which,  by  its  unyielding  character,  retards  the  growth;  the 
cortical  portion  of  the  bone  is  not  at  first  involved,  and  if  very 
thick,  as  in  the  diaphysis  of  long  bones,  it  may  become  only  super- 
ficially affected,  but  if  the  tumor  appear  where  spongy  bone  is  near 
the  surface,  as  in  the  epiphyses  of  long  bones,  the  growth  spreads  into 
the  medullary  spaces  and  it  is  difficult  to  distinsjuish  periosteal  from 
medullary  sarcomata.*  They  are  quite  malignant  ^  and  usually  con- 
tain all  the  varieties  of  sarcoma  tissue,  but  the  spindle  cell-tissue 
predominates  in  most  cases,  especially  in  those  enormous  tumors 
which  are  developed  on  the  ends  of  the  great  bones  of  the  extremi- 

1  T.  Billroth.  2  e.  Rindfieisch.  3  t.  Holmes.  ^  R.  Virchow. 


THE  DISEASES   OF  BONE.  105 

ties.^  The  meilullary  form,  myeloid  tumor, ^  myelogenic  osteo-par- 
comata,^  appear  especially  in  the  jaws,  as  ejmlis;  *  next  in  the  tibia, 
radius,  and  ulna;  these  tumors  often  contain  mucous  cysts  and 
spherical  or  branched  osseous  formations,  circumscribetl  nodules 
mostly  forming  in  the  medullary  cavity,  which  gradually  destroy  the 
bone;  but  new  bone  is  constantly  developed  from  the  periosteum, 
so  that  the  tumor,  if  very  large,  often  remains  covered,  eiitirelv  or 
partially,  by  a  shell  of  bone,  which  appears  j)uffed  uj)  like  a  blad- 
der; in  the  lower  extremity  they  beiome  very  vascular;  small  trau- 
matic ancurisn)s  develop  in  them  with  the  true  aneurismal  murmur; 
cysts  also  develop  in  them;  they  are  usually  solitary,  rarely  generally 
infectious;  they  appear  in  the  jaws  at  the  second  dentition,  and  in 
the  long  bones  at  middle  age."  ^\^^en  the  growth  is  periosteal  the 
fibrous  tumor  resembles  it,  but  the  sarcoma  is  softer,  more  elastic, 
and  vascular;  when  within  bone  it  is  dillicult  to  distinguish  sarcoma 
from  other  innocent  tumors;  it  differs  from  cancer  chieliy  in  that  it 
is  of  slower  growth,  has  a  broadly  rounded  shape,  and  its  seat  is  in 
the  articular  end  rather  than  in  tlie  shaft  of  a  bone;  in  the  absence 
of  glandular  disease  and  of  all  cachexia,  though  three  or  four  years 
may  have  elapsed.-  Excision  is  the  only  available  remedj-,  and 
should  be  resorted  to  without  delay,  the  base  being  thoroughly  re- 
moved.2 

4.  Fibromata^  springing  from  the  periosteum  are  quite  frequent, 
and  are  generally  conqiosed  of  fibres  and  spindle-shaped  cells;  the 
latter  m.ay  preponderate,  giving  the  growth  the  character  of  a  fibro- 
sarcoma ;  the  periosteiuu  of  the  bones  of  the  skull  and  face,  especi- 
ally the  inferior  turlnnated  bones,  is  particularly  liable  to  this  dis- 
ease ;  in  the  latter  position  the  tumors  appear  as  naso-phaiyngeal 
polypi  ;  these  tumors  may  form  in  the  interior  of  bone,  especially 
in  the  upper  jaw ;  they  are  most  common  in  the  young,  but  after 
puberty.  They  are  hard,  round,  of  slow  growth,  and  without  jiain. 
The  treatment  is  removal  by  enucleation. 

5.  Carcinomata  occurring  in  bone  may  originate  by  a  propagation 
of  the  iiidltratioM  from  cutaneous,  mucous,  or  glandular  cancers; 
but  cancer  api)an'Mtly  also  appears  originally  in  bone,  thouLrh  it  may 
have  an  epithelial  origin,  as  in  case  of  those  soft  and  (piickly  grow- 
ing cancers  which  spring  from  the  upper  end  of  the  humerus  and 
femur,  at  one  time  from  the  medulla  and  at  another  from  the 
periosteum.^  It  may  assume  various  forms,  namely,  encephaloid, 
which  is  most  common,  scirrhus,  and  e|»ithelial.  The  diagnosis'^ 
in  obscure  cases  must  be  made  in  favor  of  cancer  (1)  when  the 
tumor  commences  growth  before  puberty  or  after  middle  age,  unless 

1  E.  Riiidfleisch.  2  Sir  J.  Paget.  3  r.  Virchow.  *  E.  Nelaton- 

6  T.  Billroth. 


106  OPERATIVE  SURGERY. 

it  is  a  cartilaginous  or  bony  tumor  on  a  finger  or  toe,  or  near  an  ar- 
ticulation ;  (2)  when  the  tumor  on  or  in  a  bone  has  doubled,  or  more 
than  doubled,  its  size  in  six  months,  and  is  not  inflamed;  (3)  if,  in  ad- 
dition to  rapid  growth,  the  veins  over  the  tumor  have  much  enlarged, 
or  .the  tumor  has  protruded  far  through  ulcerated  openings,  bleeds, 
and  discharges  matters;  (4)  if,  though  the  tumor  is  not  inflamed, 
the  neighboring  lymph  glands  are  also  enlarged ;  (5)  if  the  patient 
has  lost  weio-ht  and  strength  out  of  proportion  to  the  damage  to 
health  by  pain  or  fever  or  other  accident  of  the  tumor;  (G)  if 
situated  on  the  shaft  of  any  bone  but  a  phalanx.  The  treatment  of 
all  forms  of  cancer  of  bone  nmst  be  by  amputation  when  the  disease 
is  local;  the  point  selected  must  be  as  far  as  it  may  be  safe  to  operate 
from  the  seat  of  the  malignant  growth.^ 

III.  INFLAMMATION  OF  BONE. 

The  morbid  changes  included  under  the  term  inflammation  of 
bone  are  remarkable  for  their  clinical  diversity  and  singular  ana- 
tomical uniformity;  there  is  no  deviation  from  the  physiological 
type,  except  where  pus  forms,  which  introduces  infinite  complica- 
tions into  the  whole  course  of  the  inflammatory  process,  as  repair  can 
be  brought  about  only  by  circuitous  methods."^ 

1.  Periostitis,  acute,  occurs  chiefly  in  young  persons,  and  in  its 
tvpical  forms  almost  exclusively  in  the  long  bones,  as  the  femur  and 
tibia  ;  at  first  there  is  high  fever,  not  unfrequently  a  chill,  severe 
pain  in  the  affected  part;  swelling  without  redness;  skin  tense  and 
usually  cedematous ;  every  touch  or  jar  is  very  painful.  The  inflam- 
mation may  resolve  at  this  stage,  or  progress  to  suppuration,  when 
additional  svmptoms  appear:  the  swelling  now  increases,  the  skin 
becomes  reddish,  then  brownish  red,  the  cedema  extends,  the  neigh- 
boring joint  becomes  painful  and  swells,  and  towards  the  twelfth 
day  fluctuation  is  detected.^  The  inflammation  often  occurs  in  the 
periosteum  of  the  third  phalanx,  felon,  causing  great  suffering,  and 
terminating  in  necrosis.  In  the  early  stage  of  the  disease  in  the 
long  bones  apply  the  strong  tinct.  iodine,  and  repeat  when  the  vesicles 
dry  up;^  add  ice,  if,  when  applied  until  the  deeper  parts  are  cold, 
it  is  afrreeable  and  the  pain  subsides.  When  effusion  takes  place 
and  is  confined  beneath  the  dense  fibrous  periosteal  layer,  free  incision 
down  to  the  bone  gives  immense  relief;  as  the  object  is  to  relieve  ten- 
sion, the  incision  should  be  made  as  soon  as  this  condition  clearly 
exists,  though  pus  may  not  have  formed  ;  this  practice  is  especially 
important  when  the  upper  part  of  the  shaft  or  the  articular  end  of 
a  bone  is  affected.*  The  local  applications  should  now  be  soothing, 
as  fomentations,  and  carbolized  solutions   should   be  freely  used  in 

1  Sir  J.  Paget.  2  £.  Rindfleisch.  «  T.  Billroth.  <  T.  Bryant. 


THE  DISEASES   OF  BONE.  107 

the  wound  to  arrest  septic  changes.  Pus  should  be  freely  evacuated 
wherever  it  may  be  found,  and  free  drainage  secured  by  position  or 
drains.  The  general  treatment  should  consist  of  anodynes,  with 
laxatives  and  low  diet,  to  relieve  pain  and  inllammation;  and  tonics 
and  nutritious  food  when  suppuration  is  established. 

2.  Osteo-myelitis,  acute,  is  an  inllaunnation  of  the  medulla  of 
bones;  it  occurs  in  the  young  and  is  generally  caused  l)y  injury  ;  the 
symptoms  are,  intense  aching  pain  at  the  scat  of  inllaiuniation  which 
is  relii'ved  only  by  perforation  of  the  bone  ;  swelling,  which  begins 
as  a  pulHness  but  has  a  peculiarly  aln-upt  margin  and  as  the  disease 
spreads  advances  up  the  limb;  red  and  hcpalized  apjtcarance  of  the 
marrow,  seen  in  the  bone  of  a  stump;  globules  of  oil  mixed  with 
the  pus  discharged;  irritative  fever  with  great  restlessness,  and  in 
bad  cases  delirium.^  The  symptoms  so  closely  resemble  those  of 
suppurative  periostitis  that  in  many  cases  it  cannot  be  discovered 
whether  only  the  jjeriosteum  is  affected  or  the  medulla  also;  but  if 
while  there  is  great  pain  and  fever,  or  complete  inability  to  move  the 
limb  on  account  of  pain,  swelling  does  not  occur  for  several  days,  it 
is  to  be  inferred  that  the  seat  of  the  inllammation  is  the  inedidlary 
cavity.'^  The  inflammation  may  induce  acute  periosteal  abscess, 
thrombosis,  pvit^mia,  necrosis,  and  the  separation  of  the  epiphysis  l)y 
the  suppuration  of  the  epiphyseal  cartilage.  The  indications  of 
treatment  are  :  removal  to  the  open  air;  elevation  of  the  part,  but 
with  depending  opening  for  free  discharge  of  pus;  local  applications 
of  ice  when  agreeable  to  the  patient;  free  use  of  disinfectants;  ap- 
plication of  the  strong  tincture  of  iodine;  tonics,  as  quinine  and  iron. 
If  antiphlogistic  remedies  fail  and  the  pain  increases  to  a  violent 
degree,  nuUce  free  incision  and  trephine  the  bone  to  relieve  the  ten- 
sion ;8  if  the  integrity  of  the  bone  is  destroyed,  resect,  or  amputate. 
Amputation  in  the  continuity  of  the  affected  bone  is  injurious,  but 
disarticulation  of  the  bone  at  an  early  j)eriod,  before  pyjBmia  occurs, 
has  given  good  results.^ 

It  is  inaiiitained  that  extensive  wounds  are  bad  in  feverish  patient?,  and  pre- 
dispose to  pyaemia,  and  that  disarticulation  is  erroneous  because,  first,  the  tliag- 
nosis  is  not  certain,  second,  the  resuhs  obtained  are  uncertain,  and,  tliird.  the 
proi^nosis  in  exarticulation  of  large  limbs,  for  acute  disease  of  the  bone,  is  always 
doubtful.- 

IV.  CARIES  OF  BONE. 

Periof^titis  and  osteo-myelitis  may  terminate  in  circumscribed  sup- 
puration, which  results  in  ulceration  or  caries  of  bone. 

1.  Superficial  caries  corresponds  to  an  indolent  ulcer  of  the 
skin;  the  surface  of  bone  exhibits  a  loss  of  substance  which  gradu- 

1  J.  A.  Lidell.  2  T.  Billroth.  8  l.  Bauer. 


108  OPERATIVE  SURGERY. 

ally  increases  in  depth,  but  remains  shallow,  and  continually  throws 
off  small  quantities  of  pus  and  shreds  of  decaying  structures,  de- 
rived from  the  denuded  medullary  tissue,  which  at  a  certain  depth 
is  in  a  state  of  hyperajuiic  proliferation,  passing  near  the  surface 
into  an  exceedingly  dense  corpuscular  infiltration;  the  cells  occupy 
all  the  pores  of  the  bone  tissue  and  leave  no  room  for  blood  or 
blood-vessels,  which  are  finally  converted,  with  the  cells,  into  molec- 
ular debris.^  The  symptoms  are  tenderness,  oedema,  severe  boring 
and  tearing  pains  at  night."'^  The  process  of  cure  consists  in  the  de- 
tachment and  removal  of  the  necrosed  portions  or  particles  of  bone, 
cessation  of  the  process  of  proliferation,  shrinking  together  of  the 
interstitial  granulation  tissue,  and  its  transformation  into  cicatricial 
tissue.*^  The  indications  as  to  general  treatment  are  the  impi'ove- 
ment  of  the  health  by  tonics  and  hygienic  measures;  the  local  treat- 
ment is:  (1)  Removal  of  the  purulent  debris;  (2)  arrest  of  the  ca- 
rious process;  (3)  healing  of  the  surface.  If  the  caries  affects  the 
shaft  of  a  long  bone,  easily  accessible,  as  the  tibia,  expose  the  carious 
bone  by  a  free  incision,  whether  the  pus  is  still  contained  in  an  ab- 
scess or  is  escaping  from  a  sinus;  cleanse  the  exposed  surface  of 
all  foreign  matters;  very  gently  remove,  with  forceps  or  periosteal 
knife  or  gouge,  every  particle  of  dead  bone,  without  injury  to  the 
living  bone;  apply  the  strong  solution  of  carbolic  acid,  1  in  20,  to  the 
surface  of  bone;  complete  the  dressing  by  packing  the  wound  with 
carbolized  oil,  1  in  10;  place  the  part  in  a  condition  of  perfect  rest, 
using  plastic  apparatus  if  necessary;  renew  these  dressings  only 
when  required  for  cleanliness,  and  change  the  application  to  bals. 
Peru  when  granulations  cover  the  bone. 

2.  Central  caries  usually  begins  in  a  hollow  bone  as  an  osteo- 
myelitis; the  inflammation  extends  to  the  inner  surface  of  the  cor- 
tical substance,  which  is  dissolved,  and  pus  may  form  quite  early  in 
the  centre  of  the  new  formation,  creating  what  is  known  as  a  bone 
abscess;  the  periosteum  is  thickened,  new  bony  deposits  form  from 
the  surface  of  the  bone,  and  the  hollow  bone  is  thus  enlarged  exter- 
nally at  the  point  where  the  abscess  forms,  giving  it  the  appearance 
of  inflation;  the  central  caries  may  be  accompanied  by  partial  necrosis 
of  portions  of  bone  on  the  internal  surface  of  the  cortical  substance.* 
These  bone  abscesses  more  often  form  in  the  spongy  portion  of  long 
bones,  especially  of  the  tibia.  The  sym])toms  are  very  often  uncer- 
tain, as  the  chronic  inflammation  may  exist  deep  in  the  bone;  there 
may  be  only  a  dull  pain,  with  but  slight  impairment  of  function;  it  is 
only  when  there  is  severe  pain  on  pressure  and  oedema  of  the  skin, 
showing  that  the  periosteum  is  involved,  that  the  case  becomes  more 
apparent;  but  it  may  happen  that  the  true  state  of  the  disease  can 
1  E.  Rindfleisch.  2  T.  Billroth. 


THE  DISEASES   OF  DONE.  109 

be  determined  only  when  perforation  has  taken  place  and  the  probe 
may  be  passed  into  the  cavity.^  The  most  reliable  symptoms,  when 
present,  are  severe,  lonji  continued,  and  paroxysmal  pain  and  local 
swelling:,  often  at  a  single  point,  wliere  there  is  extreme  tender- 
ness on  pressure.'-  The  treatment  is  trci)biniMg;  mark  on  the  skin 
the  precise  spot  where  the  tenderness  and  pain  are  located  ;  give 
an  anaesthetic  and  make  a  crucial  incision  down  to  tlie  bone,  raise 
the  periosteum  to  the  re(lui^ite  extent,  and  with  the  trephine  open 
the  cavity. 2  If  no  pus  is  found,  puilcture  the  surrounding  bone 
with  a  strong  awl  or  drill,  for  the  pus  has  been  found  just  beside 
the  track  of  the  trephine.^  The  abscess  cavity  should  be  cleansed 
and  filled  with  pledgets  of  lint  saturated  with  bals.  Peru. 

A  less  severe  operation  is  at  times  of  equal  value,  namely,  puncture  with  a 
drill,  especially  when  the  seat  of  the  abscess  is  not  well  delhied.-* 

3.  Internal  and  external  caries  may  be  accompanied  by  necrosis 
and  by  suppuration  or  osteo- plastic  periostitis  in  the  same  hollow 
bone;  abscesses  appear  at  different  points;  rotten  bone  and  a  seques- 
trum may,  at  the  same  time,  be  felt  with  a  probe;  at  one  point  the 
surface  is  exposed,  and  at  another  the  interior;  the  whole  bone  is 
thickened,  as  is  the  periosteum;  thin  pus  escapes  from  the  fistulous 
openings;  the  surface  is  thickly  covered  with  porous  osteophytes; 
necrosed  portions  lie  here  and  there;  the  medullary  cavity  is  j)artly 
filled  with  porous  bony  substance,  and  round  holes  are  found  con- 
taining necrosed  bone.^  The  proper  treatment  of  a  bone  in  this 
condition  is  usually  extirpation  or  amputation,  as  recovery  cannot 
be  expected  by  any  method  of  treatment.^ 

V.   NECROSIS  OF  BONE. 

The  complete  arrest  of  nutrition  in  a  certain  portion  of  bone,  which 
results  in  its  death,  is  usually  due  to  suppurative  periostitis  as  a  prox- 
imate cause,  even  in  traumatic  cases,  though  not  an  invariable  con- 
sequence; the  pus  excites  a  sequestrating  inflammation  both  in  the 
periosteum  and  the  bone;  the  former  being  converted  into  a  pyogenic 
membrane,  is  separated  from  the  bone,  while  a  fungating  ostitis,  fed 
by  the  medulla,  is  set  up  in  the  bone,  which  shuts  of?  the  organism 
by  granulation  tissue;  the  dead  bone  is  called  the  secpiestrum,  and 
the  fungating  ostitis  which  separates  it,  demarcation ;  the  detached 
periosteum  develops  a  layer  of  new  bone  immediately  under  the 
pyogenic  surface,  forming  a  capsule,  the  involucrum,  which  incloses 
the  se(juestra.^ 

1.  Partial  necrosis  of  the  diaphysis  occurs  when  the  outermost 

1  T.  Billroth.  2  C.  Jacksou.  «  T.  Holmes.  *  T.  Bryant. 

6  E.  liindtleisch. 


110  OPERATIVE  SURGERY. 

layers  of  the  compact  substance  of  bone  have  been  too  long  cut  off 
from  the  circulation  and  nutrition  to  allow  their  vitality  being  re- 
stored from  the  medulla;  the  fungating  ostitis  does  the  work  of  a 
sequestrating  inflammation,  detaching  the  lamellae  of  dead  bone  and 
mingling  them  with  the  pus  which  fills  the  abscess  cavity.^  The 
presence  of  dead  tissue  is  recognized  when  it  is  exposed  by  its  white 
appearance,  with  dark  places  if  it  is  situated  deeply.  Only  the  probe 
introduced  through  sinuses  can  exactly  determine  its  presence;  in 
addition,  there  is  increased  thickness  due  to  the  new  formation  of 
bone.  The  treatment  at  fii'st  should  be  limited  to  keeping  the  fistulae 
clean;  chemical  solution  of  the  sequestrum  is  liable  to  affect  injuri- 
ously the  new-formed  bone,  and  thus  do  harm;  mechanical  removal 
of  the  dead  bone  is  the  only  proper  method;  but  it  is  important  not 
to  attempt  removal  until  the  dead  is  completely  separated  from  the 
living  bone,  for  the  dead  bone  can  rarely  be  detached  without  re- 
moving a  good  deal  of  the  healthy  and  of  the  newly-formed  bone; 
nor  is  the  involucrum  firm  enough  before  complete  detachment.2 
The  complete  separation  of  a  superficial  sequestrum  is  generally 
easily  made  out  with  a  probe. 

2.  Total  necrosis  of  the  diaphysis  results  from  suppuration  of 
the  periosteum  and  medulla:  the  pus  from  the  periosteum  perforates 
the  soft  tissues  and  escapes,  but  that  from  the  medulla  falls  to  detri- 
tus or  putrefies  within  the  bone;  the  process  of  detachment  is  effected 
by  an  interstitial  proliferation  of  granulations  in  the  edges  of  the 
living  bone  by  which  a  slight  amount  of  bone  is  consumed;  the  se- 
questrum now  lies  loose  in  a  pus  cavity;  this  detachment  of  thick 
hollow  bones  requires  months  and  sometimes  more  than  a  year; 
meantime  the  periosteum  has  formed  a  shell  of  new  bone  which  in 
time  becomes  very  thick,  and  finally  compact.^  The  probe  is  the 
guide  to  determine  whether  the  bone  is  loose,  but,  it  is  difficult  to 
decide  on  the  mobility  of  a  large  sequestrum,  especially  when  the 
bone  is  curved,  as  the  lower  jaw;  the  duration  of  the  process  and 
the  thickness  of  the  bony  case  are  important  aids ;  most  sequestra 
are  usually  detached  in  eight  or  ten  months,  and  in  a  year,  even  an 
entire  diaphysis  usually  becomes  detached,  completely  separated 
from  its  connections. ^  The  treatment  is,  in  general,  the  same  as  in 
partial  necrosis ;  but  this  distinction  must  be  made,  namely,  if  the 
formation  of  bone  be  still  weak,  though  the  sequestrum  be  already 
detached,  it  is  Avell  to  postpone  the  extraction  in  case  of  the  humerus, 
tibia,  and  femur,  so  that  the  formation  of  bone  may  be  firmer  ;2  it 
may  be  necessary  occasionally  to  resect  when  no  new  bone  exists.^ 

1  E.  Rindfleisch.  3  T.  Billroth.  3  j.  Holmes. 


THE   OPERATIONS   ON  BONES.  Ill 

CHAPTER   XIV. 

GENERAL  OPERATIONS   ON  THE  BONES. 

I.   SEQUESTROTOMY. 

The  removal  of  necrosed  bone  may  bo  effected  by  successive  slight 
operations  by  which  the  periosteum  is  gradually  separated  from  the 
dead  mass,  the  indirect  method,  or  by  a  single  formal  operation,  the 
direct  nut  hoi  I. 

1.  The  indirect  method  i  is  to  be  preferred  when  the  bone  is 
superficial  and  it  is  desirable  to  preserve  its  contour, ^  as  in  the 
removal  of  lar^e  sections  of  the  tibia,  the  lower  and  upper  jaw, 
the  clavicle.  This  method  consists  in  separating  from  time  to  time 
the  diseased  periosteum  from  the  bone  beneath  with  the  handle  of 
the  scalpel  or  with  a  small  spatula,  the  periosteum  not  being  raised 
beyond  the  limits  of  the  disease.  By  this  means  free  escape  for  pus 
is  constantly  maintained,  the  new-formed  bone  becomes  more  per- 
fectly adapted  to  the  space  occupied  by  the  old,  and  the  tissue  of  the 
new  structure  is  more  firm.  When  at  length  the  sequestrum  is  sep- 
arated it  is  readily  raised  from  its  bed  with  scarcely  the  appearance 
of  blood,  and  the  shape  and  function  of  the  bone  is  largely  pre- 
served. 

2.  The  direct  method  is  often  tedious,  and  much  complicated 
by  the  oozing  of  blood  into  the  wound;  to  avoid  bleeding,  the  ves- 
sels of  the  limb  should,  as  far  as  jjraeticable,  be  emptied  of  their 
blooil;  as  the  elastic  bandage,  so  effectual  in  removing  blood  from 
the  limb,  would  be  liable  to  force  infectious  matters  into  the  meshes 
of  the  cellular  tissues,  and  the  extremities  of  lymphatic  vessels,  it 
is  better  to  empty  the  limb  as  completely  as  possible  by  causing  it 
to  be  raised  high  in  the  air  for  a  few  moments,  and  then  apply 
the  elastic  bandage  or  tubing  above  the  point  of  operation.^  The 
operation  is  as  follows:  ^  If  the  opening  in  the  bony  case  is  large, 
and  the  se(iuestriun  small,  attempt  the  direct  removal  with  strong 
forceps  through  this  openiu'i;  if  this  is  impracticable,  with  a  stout 
knife  make  an  inei>ion  through  the  soft  parts  down  to  the  bony  case 
from  one  fistulous  oj)ening  to  another;  with  a  pcriosteotoiue  draw  the 
thickened  soft  parts  from  the  rough  surface  of  the  bony  case  to  just 
sufficient  extent  ;  remove  this  exposed  portion  with  a  saw,  or  a 
chisel  and  hammer,  or  gnawing  forceps;  the  sequestrum  being  ex- 
posed, attempt  its  removal  by  elevators  or  strong  forceps;  first  move 
it  gently  in  its  case  in  different  directions  until  free  from  all  spiculie; 

1  J.  R.  Wood.        2  Von  I.aiigenbeck.        8  F.  Esmakch.         •»  T.  Billroth. 


112  OPERATIVE  SURGERY. 

if  the  sequestrum  is  not  detached,  avoid  forcing  it  out,  but  wait  a 
few  weeks  or  montlis  until  its  separation  is  complete.  After  the 
operation  the  suppurating  cavity  is  to  be  kept  clean,  and  the  parts 
maintained  in  a  state  of  rest;  the  ossifying  granulations  fill  the  cav- 
ity slowly,  and  the  fistulje  may  remain  open  for  a  long  period,  but 
the  process  of  closure  cannot  be  hastened  unless  the  walls  become 
sclerosed  and  cease  to  granulate,  when  the  application  of  the  hot 
iron  to  the  cavity,  or  the  chisel  to  the  fistulas,  may  be  beneficial. 

II.    RESECTION. 

Extirpation  of  bone  in  part  or  whole  is  frequently  required,  as 
after  injuries  which  have  destroyed  their  vitality,  or  after  diseases 
which  have  resulted  in  necrosis,  or  in  the  removal  of  tumors.  But 
such  an  operation  is  justifiable  only  when  it  is  evident  that  resection 
is  preferable  to  every  other  remedial  measure.^  When  the  opera- 
tion is  undertaken  it  must  be  so  planned  and  executed  as  to  become 
the  first  step  in  a  process  of  repair  by  which  a  part  is  restored  to 
more  or  less  complete  usefulness  that  would  otherwise  have  been 
sacrificed.  2 

1.  The  indications  for  resection  must  be  determined  by  the  con- 
dition of  the  patient  and  of  the  diseased  part.  In  general  the  opera- 
tion is  indicated  only  when  the  general  health  admits;  for  if  the 
patient  is  suffering  from  a  progressively  wasting  disease,  as  tubercu- 
losis or  marasmus,  which  will  necessarily  prove  fatal,  resection  would 
be  unwise,  as  repair  would  not  follow.^  In  injuries,  as  gunshot,  only 
such  fragments  of  bone  should  be  removed  as  are  nearly  or  quite 
detached  from  the  periosteum.  In  caries  of  hollow  bone  the  ulcer 
may  be  thoroughly  cleaned  out  with  the  gouge  and  the  cavity  be 
allowed  to  close  by  granulation,*  but  if  the  bone  is  small,  extirpation 
may  be  necessary  to  arrest  the  process  at  once.^  If  a  hollow  bone 
is  affected  throughout,  as  with  periostitis,  external  and  internal 
caries,  partial  internal  and  external  necrosis,  extirpation  of  the 
entire  bone  may  be  required,  as  the  only  alternative  of  amputation. * 
Tumors  of  bone,''  if  not  malignant,  must, be  removed  from  their  lo- 
cality, but  if  malignant,  extirpation  of  the  bone  or  wide  resection  is 
necessary. 

2.  The  time  of  operating  after  an  injury,  as  a  gunshot,  should, 
if  possible,  be  within  twenty-four  hours  of  the  accident,  or  pri- 
mary; if  it  is  delayed  beyond  this  period  it  should  not  be  performed 
until  the  intermediary  stage  of  inflammation  is  passed.^  If  the  bone 
is  necrosed  the  invariable  rule  should  be  not  to  attempt  removal 
before  complete  detachment,  because  the   dead  bone  can  rarely  be 

1  F.  C.  Skey.      2  a.  AVagaer.       3  T.  Billroth.      ■*  C  Sedillot.      5  Sir  J.  Paget 
8  G.  A.  Otis. 


THE   OPERATIONS   ON  BONES. 


113 


sawed  out  without  removing  healthy  and  newly-formed  bone;  and  the 
new  bone  is  not  firm  enough  before  the  sequestrum  is  detaehed.^ 


3.  The  instruments  required  in  resection  may  be  few  or  many, 
both  in  number  and  variety,  according  to  the  nature  of  the  case. 
(1.)  The  knife  (Figs.  75  and  76)  should  be  broad  and  firmly  set  in  a 


^ 


Fig. 


Fig.  78.3 


Fig.  79.'* 


routrh  handle,  which  may  or  may  not  terminate  in  a  periosteotome. 
(2.)  The  retractor  may  consist  of  broad  metal  plates  properly  curved 
(Figs.  77,  78),  or  take  the  form  of  hooks  (Fig.  70);  the  latter  are 
less  liable  to  slip  out  of  the  wound,  but  do  not  so  effectually  open  it. 


Fig.  81. 'i 


(3.)  The  periosteotome  takes  many  forms  (Figs.  80,  81);  it  is  al- 
ways a  blunt  instrument  and  in  its  use  care  must  be  taken  not  to 
contuse  the  periosteum  when  it  is  desirable  to  preserve  its  function. 


1  T.  Billroth. 
6  H.  B.  Sands. 


2  G.  Buck, 
c  L.  A.  Sayre. 


8  W.  Parker. 


*  G.  C.  Blackmail. 


lU 


OPERATIVE   SURGERY. 


(4.)   The    bone-cutting   instruments  are    numerous    and    important. 
The  straight  bone  forceps  ^  (Fig.  82)  is  a  most  useful  instrument 


Fig.  82.  Fig.  83.  Fig.  84.  Fig.  85.  Fig.  86. 

in  the  section  of  the  small  bones,  wherever  it  can  be  brought  to 
bear.  But  frequently  it  is  quite  difHcult  to  reach  the  part,  which 
may  be  more  readily  divided  with  the  forceps  than  the  saw,  unless 
the  blades  are  curved  at  a  considerable  angle;  in  such  cases  a  for- 
ceps curved  (Fig.  83,  or  Fig.  84)  will  be  found  serviceable.  The 
bone  gnawing  forceps  (Figs.  85,  8fi),  or  rongeur,  is  indispensable  in 
many  resections,  as  it  enables  the  operator  to  remove  projecting 
parts  not  accessible  to  other  instruments. 
The  saw  in  one  of  its  various  forms  is  neces- 
sary. The  chain  saw  (Fig.  87)  consists  of 
a  number  of  pieces,  with  movable  articula- 
tions, terminated  at  each  extremity  by  han- 
dles with  which  it  is  woi'ked. 

To  use  this  saw  one  handle  is  removed  from  hook, 
B,  and  a  needle,  c,  armed  with  a  strong  thread,  is 
C  attached  to  this  end;  the  needle  is  passed  under  the 
bone,  and  the  saw  drawn  into  its  position,  with  the 
cutting  edge  upwards,  and  the  handle  is  then  reat- 
tached; the  operator,  grasping  the  handles,  draws 
the  saw  alternately  from  side  to  side,  until  the  bone 
is  divided;  there  is  great  danger  of  breaking  this 
saw  if  it  is  worked  carelessly;  it  should  be  drawn 
from  side  to  side  steadily,  at  an  angle  of  45^  to  the 
long  axis  of  the  bone.  The  sections  mav  consist  of 
metallic  beads  strimg  on  a  wire  with  handles;  such 
a  saw  will  act  efficiently  in  whatever  direction  it  is 
beld.i 


Other   saws,  of  peculiar  shape,  are  often 
useful  in  the  removal  of  certain  bones,  though 
not  absolutely  essential;  the  saw  (Fig.  88)  with  a  movable  back, 
1  R.  Listen.  2  TiEMANN  &  Co. 


THE   OPERATIOXS   OX  BOXES. 


115 


may  be  used  to  advantajre  in  most  resections  of  bones  of  the  ex- 
tremities; in  the  removal  of  the  superior  maxilla,  the  right  and  left 
bone  saws  (Figs.  8Jt.  90)  enable  the  operator  to  separate  its  superior 


attachments  with  great  facility;  a  small  straight  saw  (Fig.  91)  is  often 
required  and  when  it  is  necessary  to  use  a  part  of  the  edge,  an  India- 
rubber  tube  may  be  drawn  over  the  part  unused  to  prevent   its  in- 


juring the  soft  parts;  occasionally  a  saw  having  a  circular  as  well  as  a 
straight  edge^  (Fig-  9-)  is  required  in  removing  sharp  points,  or  thin 


^Q^SSC 


Fig.  91. 


Fig.  92. 


bones;  finally,  a  saw^  is  essential,  whicli  may  be  taken  from  its  posi- 
tion (Fig.  93)  where  it  is  firmly  held  by  a  spring,  connected  with  the 


(T 


^ 


NH 


Fig.  93. 


handle,  and  passed  under  the  bone,  if  required,  and  the  ends,  being 
reattached  in  the  frame,  the  bone  is  as  readily  divided  from  beneath 


1  R.  Hey. 


R.  Butcher;  S^inanowsky. 


116 


OPERATIVE  SURGERY. 


as  from  above;  the  saw  may  be  turned  laterally  also,  or  be  made  to 
cut  in  a  curve;  the  tension  of  the  saw  is  regulated  by  a  spring  in- 
closed in  the  handle.  The  gouges,  the  chisel  (Fig.  94),  and  the 
mallet  (Fig.    95),   are  often  required;   to  thoroughly   clean   out  all 


Fig.  95. 


Fig.  94.1 


forms  of  carious  cavities,  two  or  more  gouges  are  necessary  with 
different  cutting  edges ;  the  mallet  may  be  of  wood  or  metal  with  a 
firm  handle.  (5.)  The  seizing  forceps  may  be  the  common  dressing 
forceps  (Fig.  96)  for  small  fragments,  and  larger  forceps  for  large 


Fig.  96. 


Fig.  97.2 


Fig.  99. 


fragments  (Fig.  97);  they  should  also  have  straight  and  curved  beaks 
(Figs.  98,  99)  to  seize  fragments  that  are  concealed.  Other  instru- 
ments may  be  used,  as  the  conical  screw,  the  terefond. 

4.  The  operation  is  as  follows:    The  anaesthetic  having  been  ad- 
ministered, the  elastic  bandage  should  be  applied  unless  there  is  in- 

1  J.  T.  Darbv.  2  Sir  W.  Fergusson. 


THE    OPERATIONS   ON  BONES.  117 

filtration  of  the;  oclliilar  tissue  witli  Hiiids,  in  which  case  it  should  be 
omitted.  1  Tlie  method  of  operating  must  be  adapted  to  each  partic- 
ular ease.  In  shot  fractures  the  extirpation  of  fragments  must  be 
through  openings  extending  from  the  wound;  in  necrosis  the  sinuses 
are  guides  for  incisions;  in  tlie  removal  of  the  bone  for  morbid 
growths,  the  incisions  must  be  largely  in  the  direction  of  the  tumor. 
The  incision  in  general  should  be  made  as  nearly  as  possible  over 
the  bone  to  be  removed,  and  distant  from  important  blood-vessels 
and  nerves;  the  soft  parts  should  not  be  destroyed,  except  so  far 
as  they  have  undergone  degeneration,  or  interfere  with  the  proper 
closure  of  the  wound  ;  injuries  to  blood-vessels  and  nerves  lvin<r 
in  the  track  of  the  incision  should  be  scrupulously  avoided  by 
drawing  them  aside;  muscles  and  tendons  should,  if  possible,  not 
be  divided,  nor  their  attachments  incised,  but  should  be  separated 
to  the  least  practicable  extent  with  a  blunt  instrument.  The  bone 
being  exposed  to  the  desired  extent,  the  next  care  of  the  operator 
should  be  to  preserve  in  the  wound,  and,  as  far  as  possible,  in  its 
original  position,  the  periosteum  of  the  bone  to  be  removed,  in  order 
to  the  reproduction  of  sufficient  new  bone  to  preserve  the  function 
of  the  part.'^  The  periosteum  is  best  preserved  by  first  incisino-  it  to 
the  extent  of  the  bone  to  be  removed,  and  then  separatino-  it  with 
the  periosteal  knife.  The  periosteum  being  separated,  the  bone  must 
be  divided  by  cutting  forceps  or  the  saw,  and  each  portion  separ- 
ately removed;  if  the  saw  is  used,  the  soft  j)arts  should  be  carefully 
protected  by  compresses  or  a  spatula  introduced  underneath  it.  In 
some  cases  the  interior  of  carious  cancellated  bones  may  be  scooped 
out,  and  the  external  shell  be  left  as  the  basis  of  new  bone.*  The 
scoop  may  be  a  curved  chisel,  the  periosteal  knife,  or  other  instru- 
ment which  may  be  applied  to  the  interior  of  the  carious  cavity. 

6.  The  treatment  of  resection  ■wounds  should  secure  rest  and 
freedom  from  all  sources  of  irritation.  Kest  is  obtained  by  appara- 
tus which  is  adapted  to  each  case;  in  general  the  immovable  appara- 
tus of  plaster  of  Paris  is  most  available  and  useful.  These  wounds 
necessarily  heal  by  granulation,  and  hence  are  to  be  treated  the 
same  as  open  wounds.  They  are  jieculiarly  liable  to  be  poisoned  by 
septic  ferments  from  the  putrefactive  matters  already  existing  in  the 
wound.  The  dressings  shoidd  therefore  be  scrupulously  antiseptic 
throughout  the  stage  j)receding  granulation,  and  sul)sequently  to 
such  degree  as  will  protect  the  granulations  from  any  infectious  mat- 
ter which  may  enter  or  form  in  the  wound.  First,  wash  and  cleanse 
the  wound  thoroughly  with  a  carbolic  acid  solution,  1  to  20;  then  fill 
it  from  the  bottom  with  masses  of  lint  saturated  in  carbolized  oil, 
1  to  20  ;  renew  the  dressings  every  twenty-four  to  forty-eiorht  hours, 

1  F.  lisMAKCH.  2  L.  oilier.  8  c.  Sc^dillot. 


118  OPERATIVE  SURGERY. 

carefully  picking  out  with  the  dressing-forceps  each  mass  of  lint,  but 
without  bruising  the  surfaces  so  that  they  bleed,  and  refilling  the 
wound  with  newly- prepared  lint  saturated  with  the  oil;  when  the 
surfaces  are  well  covered  with  granulations,  change  the  carbolized 
oil  dressing  to  balsam  of  Peru,  a  mild  but  efficient  antiseptic  ^  appli- 
cation to  granulations. 

BONES  OF  THE  UPPER  LIMBS. 

Resection  is  to  be  preferred  to  amputation,  in  the  greater  number 
of  lesions  of  the  upper  extremities,  as  the  principal  function  is  that 
of  mobility.^ 

1.  The  phalanges  may  be  resected  in  part  or  whole,  but  the  re- 
sults are  not  always  favorable,  owing  to  the  stiffness,  shortening, 
and  deformity  which  so  often  follow.  Efforts  should  be  made  to 
preserve  the  periosteum  with  a  view  to  the  production  of  new  bone 
in  the  shafts  of  the  bones  that  have  been  removed.  In  the  after 
treatment,  apply  a  splint  to  the  palmar  surface,  and  make  such  ex- 
tension as  will  maintain  the  full  length  of  the  phalanx:  The  en- 
tire phalanx  is  removed  by  an  incision  over  the  t^haft  of  the  bone  on 
the  side;  the  tendons  being  raised,  introduce  the  bone  forceps,  di- 
vide the  bone,  and  remove  the  two  halves  separately  at  their  articu- 
lation. In  removing  the  third  or  ungual  phalanx,  make  on  the 
palmar  surface  a  double  T  incision,  one  end  corresponding  to  the 
articulation,  the  other  to  the  extremity  of  the  finger;  denude  the 
phalanx  from  the  end  towards  its  base,  the  nail  rcmnining  intact. 
The  shaft  of  a  phalanx  may  be  removed  by  a  longitudinal  incision 
made  on  the  dorsal  or  lateral  aspect  of  the  ])halanx  ;  detach  the 
tendons  with  bone  forceps,  held  at  right  angles  to  its  long  axis; 
divide  the  shaft  in  two  places  equally  distant  from  its  extremities, 
and  remove  the  fragments  or  dorsum. 

2.  The  metacarpal  bones,  when  resected  for  shot  injuries,  give 
a  lai'ge  mortality,  confirming  the  precept  ^  that  operative  interfer- 
ence should  not  be  thought  of  in  such  cases.*  For  diseases,  the  ex- 
cision frequently  gives  favorable  results.  The  superficial  condition 
of  the  dorsal  aspect  of  these  bones,  and  the  important  anatomical 
relations  of  their  palmar  surface,  require  that  all  operations  for  their 
excision  be  commenced  on  the  posterior  part  or  dorsum. 

(a.)  The  entire  bone  is  removed  as  follows  :  Make  an  incision 
along  the  dorsal  surface  of  the  third  and  fourth  metacarpal  bones, 
and  on  the  radial  side  of  the  second  and  ulnar  side  of  the  fifth ;  draw 
the  extensor  tendon  on  one  side,  and  relieve  the  sides  of  the  bone  of 
the  soft  parts;  separate  the   periosteum  as  much  as   possible,    aud 

1  E.  R.  Squibb.  2  C.  St^dillot.  3  F.  Stroineyer.         4  Geo.  A.  Otis. 


THE   OPERATIONS   ON  BONES. 


119 


Fig.  100. 


divide  the  centre  with  the  bone  forcep.s  (Fig.  100),  or  with  the  chain 
saw,  the  soft  parts  being  protected  by 
a  compress  or  sjjatuhi;    the   fragments 
are  then  separately  elevated,  and  dis- 
articulated with  the  point  of  the  knife.^ 

This  operation  may  be  variously  modified, 
accordiiifj  to  the  condition  of  flie  part  af- 
fected. When  there  is  much  >wellinjj;,  make 
a  short  lateral  incision  at  eacli  extremity 
of  tlie  longitudinal  cut.^  The  incision  may 
also  be  made  between  the  tendons  of  the 
long  and  short  extensors  on  the  doi-sum  along 
the  radial  border. 3  In  resection  of  the  fifth 
metacarpal  the  cut  may  be  a  T  or  L- 

(/>.)  The  shaft  is  removed  by  a  lon- 
gitudinal incision  on  the  radial  border 
of  the  first  and  second,  on  the  ulnar 
border  of  the  fifth,  and  the  dorsal  sur- 
face of  the  third  and  fourth;  carefully  avoid  the  extensor  tendons, 
and  with  a  chain  saw  divide  at 


two  points  the  denuded  bones. 

(c.)  The  proximal  portion  of  the 
bone  is  resected  by  a  longitudinal 
incision  over  the  upper  extremity 
of  the  metacarpal  bone;  avoid 
the  extensor  tendon,  separate 
the  soft  i)arts  from  the  sides  of 
the  bone;  divide  the  bone  at  the 
requisite  point  with  bone  for- 
ceps, or  with  the  saw,  after  being 
isolated  from  the  soft  parts,  and 
as  far  as  possible  from  the  perios- 
teum ;  seize  the  fragment  with 
the  forceps  ;  raise  it  from  its  bed 
(Fig.  101),  and  disarticulate  the 
joint  with  the  point  of  the  knife. 

('/.)  In  complete  resection  the 
e.xtrendty  of  the  metacarpal  bone 
is  removed  and  its  corrcsjjonding 
carpal  bone,  by  a  single  longitu- 
dinal incision  made  in  the  direc- 
tion of  the  superior  extremity  of  Fir..  101. 
the  metacarpal  bone,   which  is  denuded  of   soft  parts,   and    sawn 

1  E.  Chassaiguac.  2  C.  Sedillot.  3  a.  Gu^rin. 


120 


OPERATIVE  SURGERY. 


at  the  proper  point;  remove  this  part  at  its  articulation,  and  then 
extirpate  the  carpal  bone. 

(e.)  The  phalangeal  extremity  of  the  metacarpal  bone  of  the  thumb 
is  removed  thus:  Make  an  incision  on  its  dorsal  surface;  draw  aside 
the  extensor  tendons  carefully ;  divide 
-with  a  chain  saw  at  the  required  point; 
seize  the  diseased  portion  with  the  forceps 
(Fig.  102),  bring  it  forward,  expose  the 
articular  extremity  to  the  point  of  the 
'knife,  by  which  it  is  readily  disarticu- 
lated. 

Or,  make  an  oblique  incision,  commencing 
half  an  inch  beyond  the  point  at  which  you 
wish  to  apply  the  saw,  from  the  middle  of  the 
dorsal  surface  of  the  metacarpal  bone  to  the 
conimissure  of  the  linger,  then  another  from 
the  same  point  to  the  next  commissure  on  the 
other  side  ;  thus  circumscribing  a  V-shaped 
flap,  with  its  base  next  the  linger;  turn  aside 
the  extensor  tendon,  detacli  the  iiiterossi  from 
the  sides  of  the  bone,  and  open  the  joint,  cut- 
ting its  anterior  and  lateral  ligaments  carefully, 
not  to  wound  the  flexor  tendons;  then  dislocate 
the  phalanx  backwards. 
Fig  102  '"  total  resection  the  incision  should  be  dor- 

sal, except^  for  the  first,  second,  and  fifth  meta- 
carpo-phalangeal  articulations  ;  in  opening  these  the  incision  should  be  lateral, 
as  the  operator  will  thus  avoid  exposing  the  extensor  tendons;  the  two  articular 
surfaces  being  exposed,  the  ligaments  ai'e  incised,  and 
the  bone  eilhei'  sawn  with  the  chain  saw,  or  divided 
with  the  bone  forceps  (Fig.  103). 

Or,  make  two  incisions,  begiiniing  at  the  middle 
of  the  dorsal  face  of  the  metacarpal  bone,  diverging 
on  either  side  to  the  commissure  of  the  finger,  and 
forming  a  V-shaped  flap,  with  its  base  towards  the  fin- 
ger. 

3.  The  radius  may  be  resected  for  necrosis 
with  excellent  results,  the  mortality  being  small, 
and  the  usefulness  of  the  hand  and  wrist  being 
well  preserved.*^     In  shot  injuries  operative  in- 
terference increases  the  mortality.^    In  the  after 
treatment  secure  rest  by  a  wire,  tin,  or  sole-leather  s])lint  apjilied  to 
the  inner  surface  of  the  arm  and  forearm,  and  use  carbolized  oil 
dressings. 

(«.)  The  lower  extremity  is  broad,  of  a  quadrilateral  form,  having 
two  articular  surfaces,  one  concave,  on  the  lower  part,  for  articula- 
tion with  the  scaphoid  and  semilunar  bones ;  the  other  on  the  inner 
1  E.  Cliassait:nac.  ^  j.  M.  Carnochau.  ^  G.  A.  Otis. 


THE   OPE  RATI  OXS   OX  BOXES. 


121 


Fig.  104. 


side,  narrow  and  concave,  to  articulate  with  the  lower  end  of  the 
ulna. 

The  anterior  and  posterior  ligaments  are  atlaclied  to  the  margin  of  the  joint, 
the  lateral  li^'unu'iit  to  the  stvioid  process;  the  posterior  surface  has  grooves  for 
the  passage  of  the  tendons  of  extensor  muscles;  the  outer  surface  of  the  styloid 
process  has  grooves  for  tendons,  and  its  base  gives  attaciimeiit  to  the  supinator 
iongus  muscle;  the  pronator  quadratus  muscle  occupies  the  lower  fourth  of  the 
anterior  surface. 

Resect  as  follows  :  make  a  loiijritudinal  incision  aloir^  the  radius 
on  its  external  anterior  border  (Y\>^.  1U4),  extending  downwards  to  a 
point  opposite,  and  a  little  behind, 
the  styloid  process  (h) ;  if  neces- 
sary, add  two  terminal  incisions 
at  the  extremities  of  the  first  one, 
extending  transversely  backwards, 
about  three  quarters  of  an  inch; 
dissect  so  as  to  expose  the  bone 
on  its  different  aspects;  make  sec- 
tion of  bone  by  means  of  the  chain 
saw;  separate  the  diseaseil  portion 
from  the  soft  parts,  and  isolate  the 
lower  part  of  the  radius  from  its 
attachments  at  the  radio-carpal  ar- 
ticulation, without  injury  to  the  artery  («),  nerves,  or  tendons.  In 
many  cases  it  will  suffice  to  make  a  simple  straight  incision  along 
the  radial  border,  over  the  part  parallel  with  its  long  axis. 

(6.)  The  shaft  is  resected  thus:  make  a  long  strai;.dit  incision  on 
the  external  aspect  of  the  bone,  parallel  with  its  shaft;  separate  the 
muscles,  and,  drawing  the  lips  of  the  wound  apart,  denude  the  bone; 
pass  the  chain  saw,  divide  the  bone  at  the  two  j)oints  selected,  and 
raise  the  fragment  from  its  bed. 

(f.)  The  head  of  the  radius  is  quite  superficial  on  its  posterior  part 
and  surrounded  by  the  orbicular  liiraiuent,  which  retains  it  in  the 
lesser  sigmoid  cavity  of  the  ulna.  Resect  by  making  a  strai'jht  in- 
cision on  the  posterior  and  external  part  of  the  arm  over  the  bone, 
divide  the  bone  cautiously,  and  raise  it  from  its  articulation  by  cut- 
ting the  ligaments  with  the  point  of  the  knife. 

((/.)  The  entire  radius  may  be  excised;  make  an  incision  along  the 
outer  surface  of  the  radius  from  the  styloid  process  to  the  head  of 
the  bone  at  the  elbow  joint ;  divide  the  fascia  along  the  outer  border 
of  the  supinator  Iongus  muscle,  and  separate  the  muscles  along  this 
line  down  to  the  bone;  incise  the  periosteum  the  length  of  the 
wound,  and  separate  it  from  the  bone;  divide  the  bone  in  the  mid- 
dle and  remove  each  extremity  separately.^ 

1  L.  Oilier. 


122 


OPERATIVE  SURGERY. 


4.  The  ulna,  like  the  radius,  may  be  resected  for  necrosis  with 
very  favorable  results,  both  in  regard  to  mortality  and  usefulness  of 
the  limb;  but  for  shot  injuries  the  mortality  is  in  the  aggregate  aug- 
mented by  operative  interference.^  The  after  treatment  is  the  same 
as  in  rejections  of  the  radius. 

(a.)  The  lower  extremity  articulates  on  its  external  surface  with 
the  radius,  but  is  excluded  from  the  wrist- 
joint;  it  has  an  anterioi*  and  posterior 
ligament  uniting  it  to  the  radius,  and  a 
lateral  lig;imeut  connecting  the  styloid 
process  to  the  carpus.  Resection  is  as 
follows :  the  hand  being  carried  outwards, 
make  a  longitudinal  incision  over  the  most 
superficial  part  of  the  extremity;  dissect 
the  periosteum  from  the  bone  to  the  re- 
quired height,  and  carry  the  chain  saw 
under  the  bone  (Fig.  105);  having  divided 
the  bone,  proceed  to  dissect  it  from  its  ar- 
ticular connections. 
Fig.  105.  (b.)  The  shaft  may  be  removed  by  a  lon- 

gitudinal incision  on  its  posterior  part,  parallel  with  the  bone,  and 
external  to  its  border;  sepai'ate  the  muscles,  detach  the  periosteum, 
make  a  section  of  the  bone  at  the  two  points  selected,  and  remove 
the  included  portion. 

When  a  large  portion  of  tlie  bone  is  to  be  removed,  make  two  or  three  sep- 
arate incisions  instead  of  one  and  remove  the  bone  in  pieces. 2  If  the  skin  is 
diseased  or  redundant,  make  two  very  long  and  slightly  curved  incisions,  with 
their  concavities  facing  each  other,  as  in  circumscribing  an  ellipse;  then  dissect 
in  front  and  behind,  as  far  as  the  radial  border  of  the  bone,  and  saw  the  bone. 

(c.)  The  upper  extremity  includes  the  olecranon  which  enters  large- 
ly into  the  formation  of  the  elbow-joint,  but  is  subcutaneous.  Resec- 
tion is  as  follows: 3  make  a  longitudinal  incision,  five  inches  in  length, 
over  the  middle  of  the  olecranon,  extending  three  inches  above  and 
two  below  it,  penetrating  to  the  bone;  divide  the  triceps  tendon  at 
its  insertion  towards  either  edge,  care  being  taken  to  avoid  cutting 
across  the  aponeurosis,  which  is  continuous  from  the  edges  of  the 
tendon  over  the  muscles  lying  on  the  posterior  part  of  the  forearm, 
and  inserted  into  the  edges  of  the  olecranon;  dissect  up  these  inser- 
tions of  the  fascia,  as  well  as  the  origins  of  the  muscles  beneath  it, 
from  the  bone  to  the  extent  of  nearly  two  inches,  which  allows  the 
olecranon  to  be  exposed,  when  the  edges  of  the  incision  may  be 
drawn  asunder  over  the  condyles;  broad,  curved  spatulas  being  used 
for  this  purjjose;  with  the  amputating  saw  cut  through  one  half  the 
i  G.  A.  Otis.  2  E.  Chassaignac.  3  g.  Buck. 


TTIE   OPERATIONS   ON  BONES.  123 

thickness  of  tlic  bone;  complete   the   section  witli  a  fine   saw,  after 
which  separate  completely  with  a  chisel  and  mallet.^ 

Ill  some  cases  betler  access  is  secured  to  the  bone  by  a  T;  in  others  by  a 
crucial  incision. - 

(a.)  The  entire  ulna  may  be  removed  by  the  following  method:  * 
rotate  the  limb  inwards  from  the  shoulder-joint,  and  carry  the  pro- 
nation of  the  forearm  so  far  as  to  cause  the  palm  of  the  hand  to  look 
directly  outwards ;  slightly  flex  the  elbow-joint  and  elevate  the  hand; 
this  twisted  position  places  the  ulna  upon  the  posterior  and  outer  as- 
pect of  the  forearm  and  renders  it  more  easily  accessible;  the  limb 
thus  placed,  the  assistants  maintaining  the  arm  and  forearm  stead- 
ily, stand  upon  the  right  side  of  the  patient,  with  a  strong,  straight, 
sharp- pointed  bistoury  make  an  incision  along  the  posterior  and 
inner  aspect  of  the  ulna,  commencing  at  the  lower  part  of  its  supe- 
rior third  and  extending  downwards  to  a  point  over  the  extremity  of 
the  styloid  process,  dividing  the  tegumentary  layer  and  fascia;  pull 
back  the  tendon  of  the  extensor  carpi  ulnaris  and  expose  the  bone; 
make  a  transverse  incision,  about  an  inch  long,  parting  from  the 
lower  extremity  of  the  first  incision,  across  the  back  of  the  wrist; 
reflect  the  superficial  tissues  and  detach  the  tendon  of  the  extensor 
carpi  ulnaris  carefully  from  its  groove  on  the  lower  part  of  the  ulna; 
now  carry  the  dissection  along  the  anterior  surface  of  the  lower  por- 
tion of  the  ulna,  and  detach  the  soft  parts  from  the  bone  as  far  as 
the  interosseous  ligament,  the  ulnar  artery  and  nerve  being  carefully 
avoided;  detach  the  soft  parts  from  the  posterior  surface  of  the  ulna, 
avoiding  injury  to  the  extensor  tendons;  divide  the  bone  at  the  lower 
part  of  the  mitldle  third,  and  separate  the  lower  fragment  from  its 
articular  connections;  prolong  the  incision  upwards,  along  the  pos- 
terior surface  of  the  ulna,  terminating  at  the  upper  part  of  the  olec- 
ranon, opposite  its  outer  edge;  to  this  join  a  terminal  incision 
transversely  across  the  back  of  the  elbow-joint,  as  far  as  the  inner 
margin  of  the  ulna;  now  dissect  the  soft  tissues  from  the  bone,  upon 
its  posterior  and  anterior  aspects,  as  far  as  the  interosseous  liga- 
ment, and  as  high  up  as  the  insertion  of  the  brachialis  internus 
muscle;  pass  a  knife,  curved  flatwise,  close  upon  its  intero<seal  mar- 
gin, grazing  the  bone,  and  dividing  the  interosseal  membrane  up- 
wards ;  the  soft  parts  being  held  apart,  and  the  interosseous  and 
ulnar  arteries  protected;  flex  the  elbow-joint  now  and  open  behind, 
by  entering  the  bistoury  close  to  the  inner  edge  of  the  olecranon, 
divide  the  attachment  of  the  triceps  extensor  by  cutting  directly  out- 
wards; protect  the  ulnar  nerve;  divide  the  lateral  ligament  and  the 
attachments  of  the  brachialis  anticus  muscle,  the  coronary  ligament, 
and  remove  the  bone  from  its  articulation. 

1  S.  D.  Gross.  -  A.  Velpeau.  3  J.  M.  (ainochan. 


124  OPERATIVE   SURGERY. 

5.  The  radius  and  ulna  may  be  removed  together,^  and  if  tlie 
periosteum  remains,  a  useful  limb  may  result.  Make  a  straight  in- 
cision the  entire  length  of  each  bone  on  the  dorsal  surfaces,  separate 
the  muscles,  and  when  the  bone  is  reached,  raise  the  periosteum  and 
detach  the  articular  extremities;  keep  the  limb  well  extended  during 
the  after  treatment. 

(n.)  The  inferior  portions  are  resected  as  follows  (Fig.  106):  The 

I  hand  being  pronated  and  held  firmly  upon  some 

1         '         I  solid  surface,  make  two  longitudinal  incisions 

\  .  I  along  the  borders  of  the  radius  and  ulna,  a,  h, 

«— Iv  4 <  c,  d ;  raise  the  soft  parts  on  both  surfaces,  in- 

\\    •.        ■11  troduce  the  fine  saw,^  and  after  dividing,  re- 

Z"-— jLil_i__J|^ ''move  the  extremities;  if  necessary,  unite  the 

/  -        ,    ^^        lower  extremities  of  these,  b,  d,  and  dissect  the 
'■  \      quadrilateral  flap,  a,  6,  c,  (Z,  thus  circumscribed; 

'   .  ' '        '    "    »      ^uj-n    ii^Q    flap   backwards  and  effect  the  disar- 
FiG.  106.  ticulation. 

(/;.)  The  superior  portions  of  both  bones  may  be  removed  by  lat- 
eral incisions,  joined  by  a  transverse  incision  over  the  joint;  remove 
the  radius  first,  denude  the  bone,  and  divide  with  the  chain  saw:  the 
head  is  disarticulated  by  dividing  the  attachment  of  the  biceps,  and 
the  orbicular  ligament;  divide  the  ulna  in  a  similar  manner,  and  dis- 
articulate, carefully  guarding  against  injuring  the  ulnar  nerve  on  its 
inner  aspect,  and  the  artery  in  front,  and  preserving  if  possible  the 
attachments  of  the  brachialis  anticus  muscle. 

6.  The  humerus  is  generally  resected  in  part,  though  it  has  been 
removed  entire. 

The  mortality  after  resection  for  disease  is  comparatively  small,  hut  for  sfiot 
injuries  it  is  nearly  double  that  in  cases  treated  by  expectant  measures,  and 
more  than  twelve  per  cent,  higher  than  in  a  large  series  of  primary  amputations 
in  the  upper  third  of  the  arm. 3  The  results  of  resection  for  disease  are  highly 
favorable  as  regards  the  functions  of  the  limb,  new  bone  rapidly  forms  and  the 
shaft  is  firmly  consolidated;  for  shot  injuries  the  repair  is  much  less  perfect,  as 
no  bony  union  took  place  ni  upwards  of  twenty-seven  per  cent,  of  the  recovered 
cases. 3 

The  resected  limb  should  be  placed  in  a  sole-leather  splint  moulded 
to  the  shoulder,  arm,  and  elbow,  and  inclosing  the  limb,  except  along 
the  course  of  the  incision;  make  such  extension  as  Avill  maintain  the 
proper  length  of  the  new-formed  bone. 

(«.)  The  lower  extremity  of  the  humerus  presents  on  its  anterior 
and  posterior  surfaces,  depressions  for  corresponding  prominences  on 
the  ulna;  the  articular  surface  is  on  a  lower  plane  than  the  condyles, 
and  the  inner  part  descends  lower  than  the  outer. 

1  R.  Compton.  2  e.  Butcher.  s  Q.  A.  Otis. 


THE   OPERATWXS   OX  BOXES. 


1-23 


The  flexor  and  extensor  muscles  of  tlie  hand  arise  from  its  condyles :  it  has 
anterior,  posterior,  and  lateral  ligaments;  the  brachial  artery  lies  in  front,  and 
the  ulnar  nerve  passes  over  the  inner  condyle  on  its  posterior  and  external 
part. 

Resect  as  follows:  make  a  straiglit  incision  on  the  posterior  and 
external  part  of  the  arm  (Fig.  107)  sufhciently  extensive  to  give  a 
free  exposure  of  the  bone,  a,  wlien  the  wound  is  separated;  denude 
the  bone  and  divide  with  the  chain  saw  ;  raise  the  cut  end  with  the 
left  hand,  or  with  forceps,  and  proceed  to  disarticidate  with  the  point 
of  the  knife,  carefully  avoiding  the  brachial  artery  in  front,  and  the 
ulnar  nerve  behind  and  at  the  inside. 

b.    Resection    of 
the   shaft    requires  \ 

the  utmost  care  to 
avoid  wounding 
the  niusculo-spiral 
nerve. 

The  lower  half  of 
the  shaft  of  the  hume- 
rus is  closely  invested  ^  ' 
witli  muscles,  as  the 
brachialis  anticus  and 
triceps;  the  upper  half 
gives  attachment  prin- 
cipally to  the  muscles 
from  the  shoulder, 
chest,  and  back,  as  the 
deltoid,  pectoralis  ma- 
jor, latissimus  dorsi, 
and  rotators;  the  bra- 
chial artery,  with  the 
median  and  ulnar  nerves,  passes  along  the  posterior  margin  of  the  biceps  mus- 
cle, and  the  superior  profunda  artery  and  musculo-spiral  nerve  wind  around 
the  posterior  and  external  part  of  the  upper  and  middle  portion  of  the  shaft. 

If  the  upper  portion  of  the  shaft  is  to  be  removed,  make  a  straight 
incision  on  the  external  part  of  the  deltoid  muscle,  care  being  taken 
not  to  extend  the  incision  upwards  so.  as  to  involve  the  circumflex 
artery  and  nerve;  when  the  lower  part  of  the  shaft  is  excised  the 
incision  should  be  along  the  outer  border  of  the  brachiidis  anticus 
muscle,  avoidiu'^i  the  musculo-spiral  and  external  cutaneous  nerves; 
the  bone  is  readily  exposed  ami  removed  to  the  required  extent. 

(f.)  The  upper  extremity  consists  of  the  head  surrounded  by  the 
capsular  ligament,  the  tuberosities  and  shaft. 

The  subscapularis  is  inserted  into  the  lesser  tuberositv;  the  supra  and  infra 
spinatus  and  teres  minor  into  its  greater  tuberosity;  the  long  head  of  the  I)icep3 
runs  through  the  capsule;  the  deltoid  covers  the  external  surface  of  the  joint. 


Fig.  107. 


126 


OPERATIVE  SURGERY. 


Resect  thus :  make  a  straight  incision,  commencing  a  little  above 
and  outside  of  the  coracoid  process,  and  half  an  inch  below  the  clav- 
icle, and  carry  it  downwards  to  the  requisite  extent  along  the  deltoid 
muscle  on  the  anterior  part  of  the  joint  ;  the  bone  is  here  quite  su- 
perficial, and  is  most  readily  exposed;  the  bicipital  fi^roove  bein" 
found,  dislodge  the  long  head  of  the  bice[)S  muscle  and  draw  it 
aside  (Fig.  108  6)  ;  divide  the  tendons  of  the  subscapularis,  supra 
and  infra  spinatus,  and  teres  minor  —  as  they  are  made  tense  by 
rotation  of  the  bone  outwards  and  inwards ;  open  the  capsule  and 
resect. 

If  the  disease  is  limited  to  the  head  of  the  bone,  the  diseased  structures  may 
possibly  be  removed  with  the  gouge,  without  involving  parts  beyond  the  cap- 
sule; if  it  is  of  greater  extent,  or  if  the  operation  is  undertaken  for  fracture  in- 
volving the  upper  j)art 
of  the  shaft,  expose  the 
bone  at  the  proper  place 
and  divide  with  the 
chain  saw  ;  elevate  the 
upper  extremity,  and 
disarticulate  with  the 
point  of  the  knife.  It  is 
not  advisable  to  remove 
merely  the  articular  sur- 
face of  the  humerus  by 
an  oblique  incision,  but 
the  whole  head  must  be 
removed  at  the  surgical 
neck.i  In  the  various 
conditions  which  inju- 
ries create,  other  meth- 
ods may  be  preferable, 
namel}',  a  V  incision,^ 
having  its  base  upwards» 
or  a  triangular  flap 3  on 
the  external  part  of  the  deltoid;'*  or  a  semicircular  incision,  commencing  at 
the  posterior  margin  of  the  acromium,  and  passing  downwards  and  forwards 
five  inches,  and  opening  into  the  articulation  above  and  behind:  a  U-shaped 
incision  which  includes  the  deltoid,  isolation  being  effected  with  a  spatula.5 

(d.)  The  entire  humerus  has  been  extirpated ;  in  one  case  the  thick- 
ened periosteum  was  left  in  the  woimd,  but  the  patient  died  of  in- 
ternal disease,  so  that  no  decision  could  be  made  as  to  the  usefulness 
of  the  extremity;  in  another  case  no  new  bone  formed,  but  the  pa- 
tient had  a  useful  arm  supported  by  a  ball  and  socket  apparatus  from 
the  shoulder.^  The  incision  must  be  the  same  as  for  the  resection 
of  the  upper  and  lower  extremity,  avoiding  carefully  the  musculo- 
spiral  nerve. 

1  C.  Heath.        2  Sabatier.      3  J.  Syme.     4F.  Stromeyer.        5  j.  e.  Erichsen. 
6  T.  Billroth. 


Fig.  108. 


THE  OPERATIONS   ON  BONES. 


12: 


7.  The  scapula  is  resected  for  shot  injuries,  necrosis,  and  morbid 
growths.  For  shot  injuries  it  is  sometimes  necessary  to  excise  un- 
detached  portions  of  bone  to  facilitate  the  extraction  of  foreign 
bodies,  and  when  there  is  great  comminution  it  may  be  advisable  to 
excise  considerable  portions  of  bone ;  there  may  be  conditions  also 
resuhing  from  lacerations  of  large  projectiles  which  would  render 
primary  extirpation  of  the  scapula  advisable;  but  as  a  rule  it  is 
better  to  wait,  after  removing  detached  fragments,  the  efforts  of 
nature  to  consolidate  the  fractured  bone,  and  resort  to  resection  as 
an  intermediary  or  secondary  measure  in  cases  of  extended  necrosis.* 
Resection  for  necrosis  should  involve  extirpation  of  the  entire  bone, 
when  tlie  disease  is  very  extensive,  as  it  is  unsafe  to  leave  portions 
of  a  flat  bone  thus  affected.-  Extirpations  of  the  entire  scapula  for 
morbid  growths  have  proved  so  successful  as  to  render  it  a  legitmate 
operation. 

Tlie  scapula  gives  attachment  to  a  large  number  of  muscles :  to  the  internal 
surface,  tltf  sub-scapularis:  to  the  ex-  '^y- 

teriial,  the  supra  and  iufra  spinattis  ;    "  ^""■~'«v^\v.  \  /         V   :», 

to  tlie  spine,  the  trapezius  and  del-  ^ 
toid  ;  to  tlie  superior  border,  the  omo- 
hyoid :  to  the  vertebral  border,  the 
serratus  maguus,  levator  anguli  scap- 
uUe,  rhouiboideus  major  and  minor; 
to  the  axillary  border,  the  triceps, 
teres  major  and  minor;  to  the  glen- 
oid cavity,  the  long  head  of  the  bi- 
ceps; to  the  coracoid  process,  the 
short  head  of  the  biceps,  coraco- 
brachialis,  and  pectoralis  minor ;  it 
articulates  with  the  humerus  and 
clavicle;  the  subscapular  artery,  the 
largest  branch  of  the  a.xillary,  de- 
scends along  the  outer  border. 

(a.)  The  body  (Fig.  109)  may 
be  removed  to  a  greater  or  less 
extent.  Make  three  incisions, 
one  over  the  whole  len«ith  of  the 


Fig.  109. 


spine,  A,  (1,  and  the  other  two  extending  from  its  extremities,  one 
upwards  to  the  root  of  the  neck,  a,  i,  the  other  downwards  to  the 
iiniile  </,  f;  dissect  the  triangidar  flaps  from  the  supra  and  infra 
spinatus  fossae,  saw  through  the  root  of  the  acromion,  and  denude 
the  posterior  and  anterior  surfaces  of  the  bone;  reverse  the  body  of 
the  scapula  from  within  outwards,  and  divide  the  part  at  the  proper 
point  with  the  saw.^ 


1  G.  A.  Otis. 


■^  S.  Rogers. 


3  A.  Vtlpcau. 


128  OPERATIVE  SURGERY. 

Or  make  a  longitudinal  incision  exteniliiig  from  the  superior  to  the  inferior 
angle  along  the  vertebral  border,  f,  b,  a  second  parallel  incision  extending  from 
the  neck  of  the  acromion  to  the  middle  of  the  external  border,  A,  e;  a  trans- 
verse incision  unites  these  along  the  spine;  dissect  the  flaps,  detach  the  muscles 
posteriorly  and  anteriorly,  and  divide  the  bone  with  the  chain  saw  or  forceps. 

For  a  tumor,  make  an  incision  commencing  at  the  superior  angle  of  the  scap- 
ula in  a  direction  obliquely  downwards  and  inwards;  a  second  incision  five 
inches  below  the  upper  end  of  the  first,  having  a  curvilinear  direction  termi- 
nating about  the  same  distance  from  its  lower  end  ;  dissect  the  integuments  to- 
wards the  axilla  and  spine,  detach  the  muscles,  separate  the  acromion  and  the 
neck  of  the  scapula,  and  remove  the  bone.i- 

(b.)  The  spine,  acromion  process,  and  angles  may  be  separately  re- 
sected. The  spine  may  be  readily  exposed,  owing  to  its  superficial 
position,  by  an  incision  made  parallel  to  its  border  (c,  d) ;  if  required, 
the  incision  may  be  curved  downwards  so  as  to  raise  a  flap;  the  bone 
being  denuded,  the  diseased  portions  may  be  removed  with  a  strong 
cutting  forceps.  To  resect  the  acromion  ^  make  a  semilunar  incision 
at  the  posterior  part  of  the  shoulder  with  the  convexity  downwards; 
pass  the  chain  saw  under  the  narrow  part  of  the  neck  of  tlie  acro- 
mion, divide  the  bone  at  this  part,  and  disarticulate  ;  or  make  a  cru- 
cial or  T  incision,  or  follow  the  track  of  sinuses  which  may  exist. 
An  angle  of  the  scapula  may  be  resected  by  a  transverse,  or  a  V, 
or  a  crucial  incision  over  the  part.  In  resection  of  a  border,  make 
the  incision  parallel  with  the  part  to  be  removed. 

(c.)  The  entire  scapula  is  removed  as  follows  ^  :  Make  an  incision 
from  the  acromion  process  to  the  posterior  edge  of  the  scapula  (f,  e,) 
and  another  from  the  centre  of  this  one  downwards  (c,  g) ;  reflect 
the  flaps  thus  formed,  separate  the  scapular  attachment  of  the  del- 
toid, and  divide  the  connections  of  the  acromial  extremity  of  the 
clavicle  ;  to  command  the  subscapular  artery,  divide  and  tie  it  with- 
out delay ;  next  cut  into  the  joint,  and  round  the  glenoid  cavity, 
hook  the  finger  under  the  coracoid  process,  so  as  to  facilitate  the 
division  of  its  muscular  and  ligamentous  attachments,  then  pulling 
back  the  bone  forcibly  with  the  left  hand,  separate  its  remaining  at- 
tachments with  rapid  sweeps  of  the  knife.  The  sub-periosteal  re- 
section may  be  made  by  the  same  incision. 

The  scapula  ma}-  be  removed  bj'  any  of  the  methods  given  for  the  excision  of 
a  part  of  the  body;  other  methods  have  been  adopted,  namely,  a  flap  formed 
by  the  incisions  a,  b,  and  b,  h  ;  or  a,  d,  joined  at  the  extremities  by  b,  h,  and 

A,  E. 

8.  The  clavicle  has  such  immediate  relations  to  the  upper  walls 
of  the  thoracic  cavity  that  operations  for  its  extirpation  must  be 
cnutiously  performed.*  In  shot  fractures,  detached  splinters  should 
always  be  immediately  extracted ;  but   extirpation  of  the  bone  for 

1  S.  D.  Gross.  2  E.  Chassaignac.  3  j.  Syme.  *    V.  Mott. 


THE   OPERATIOXS   ON  BOXES.  129 

such  injnru's  will  seltlom  be  reqtiireJ,  though  wlien  tht.-  wountl  is  un- 
coinplicatt'tl  by  si-rious  injury  of  tho  lung,  nerves,  or  great  vessels,  it 
does  not  ajjpear  that  the  operation  is  necessarily  fatal.*  Necrosed 
bone  should  he  cautiously  removed  in  order  not  to  injure  neighbor- 
ing parts.  The  removal  of  morbid  growths  involving  the  clavicle  is 
sometimes  the  most  serious  operation  in  surgery.- 

(«.)  The  scapular  extremity  is  broad  and  flat,  and  gives  attachment 
on  its  posterior  part  to  the  traj)ezius,  and  on  its  anterior  to  the  del- 
toid; it  is  bound  to  the  acromion  by  a  superior  and  inferior  ligament, 
and  to  the  coracoid  process  by  the  coraco-clavicular,  or  coracoid  and 
trapezoid  ligaments.  Resection  is  as  follows  :  make  a  crucial  incis- 
ion, of  surtiritnt  length;  raise  the  flaps,  cut  the  attachments  of  the 
deltoid  and  trapezius  muscles  and  acromio-davicular  ligaments.' 
Or,  make  a  curved  incision,  with  its  convexity  forwards  and  a  little 
outwards,  which,  reflected  backwards,  completely  exposes  the  bone; 
divide  with  the  chain  saw,  seize  it  with  the  forceps,  and  divide  the 
ligaments,  raise  the  bone,  and  detach.'* 

For  a  tumor,  make  a  crucial  incision  through  the  integuments  and  the  plat- 
j'sma  mvoides,  one  limb  nearly  in  a  line  with  the  clavicle,  and  the  other  at  right 
angles,  and  dij.-ect  the  tlaps  and  facial  coverings  successively,  down  to  the  ex- 
ternal basis  of  the  tumor;  carefully  detach  the  pectoralis  and  deltoid  muscles 
from  their  clavicular  origin,  avoiding  the  cephalic  vein,  and  divide  on  a  direc- 
tor the  fibres  of  the  trapezius  and  the  cleido-mastoid  muscles.  Disarticulate  the 
scapular  extremity  of  the  bone,  and  the  mobility  thus  communicated  to  the 
mass  facilitates  the  completion  of  the  operation:  pass  a  director  beneath  the 
bone,  as  near  to  the  sternal  articulation  as  practicable,  and  with  a  pair  of  strong 
bone  nippers  divide  it;  detach  the  subclavius  muscle  and  rhomboid  ligament.5 
Or,  make  an  elliptical  incision  from  the  middle  of  the  clavicle  backwards,  over 
the  most  prominent  part  of  the  tumor.6 

(h.)  The  entire  clavicle  may  be  resected  for  necrosis:  Make  an  in- 
cision parallel  to  its  inferior  border  extending  a  little  beyond  its 
extremities  ;  or  add  two  vertical  incisions,  of  one  to  two  inches  in 
length,  one  on  the  outside,  the  other  on  the  inside  of  the  first  in- 
cision- the  flap  resulting  from  which  divisions,  on  being  raised  up, 
completely  lays  bare  the  bone;  then  disarticulate  either  the  sternal 
or  acromial  extremity,  and  grasp  it  with  the  left  hand  in  order  to 
raise  it  up,  while  with  the  right  detach  with  the  bistoury  the  ad- 
hesions upon  its  lower  border;  or  saw  the  bone  through  its  middle, 
and  remove  the  two  halves  separately. 

For  a  tumor  operate  as  follows  :  Make  an  incision  from  the  acromial  extrem- 
ity of  the  clavicle  to  the  external  extremity  of  the  clavicle  of  the  opposite  side; 
cross  this  by  an  incision  at  right  angles  with  it,  beginning  just  below  the  middle 
of  the  sterno-mastoid  muscle,  and  extending  to  the  face  of  the  pectoralis  muscle 
below  the  middle  of  the  clavicle;  dissect  the  four  flaps  from  the  surface  of  the 

1  G.  A  Otis.  -  V.  Mott.  8  A.  Velpeau.  *  E.  Chassaignac. 

5  B.  Travers.  *  J.  Svme. 

9 


130 


OPERATIVE  SURGERY. 


tumor;  dissect  the  deltoid  muscle  from  its  anterior  edge,  and  the  trapezius  from 
its  posterior  edge,  and  divide  the  coraco-clavicular  ligament;  pass  the  chain 
saw  and  divide  the  bone;  seize  the  fragment  with  the  forceps,  and  detach  the 
soft  parts  with  the  point  of  the  knife,  the  edge  being  kept  constantly  turned  to- 
wards the  bone,  in  order  not  to  make  the  slightest  wound  of  the  soft  parts.i 

(c.)  The  sternal  extremity  is  of  a  triangular  form,  and  has  the  fol- 
lowing important  relations:  — 

On  its  postero-superior  surface  to  the  sterno-mastoid  and  sterno-hyoid  mus- 
cles, and  on  its  anterior  surface  to 
the  pectoralis  major  muscle;  poste- 
riorly it  is  in  near  relation  with  the 
pleura,  internal  mammary  arterj', 
subclavian  vein,  and  transverse  cer- 
vical artery;  the  innominata  is  on 
the  right,  and  the  thoracic  duct  on 
the  left  side. 

Resect  as  follows  :  Make 
(Fig.  110)  an  incision  curved 
downwards,  the  degree  of  the 
curvature  depending  upon  the 
size  of  the  bone,  but  always  so 
arranged  as  to  enable  the  ope- 
rator to  raise  it  by  dissection 
to  the  upper  part ;  after  rais- 
ing the  flap,  instead  of  sepa- 
rating the  muscles,  pass  a  chain 
saw  at  the  point  where  the  bone  is  to  be  divided;  remove  the  frag- 
ment by  carefully  disarticulating  it  with  the  point  of  the  knife,  and 
avoid  wounding  the  important  parts  posteriorly. 

For  a  large  tumor,  the  following  operation  was  performed  :  A  semilunar  in- 
cision, exposing  the  pectoralis  major  muscle,  Avas  made  from  the  sterno-clavicu- 
lar  articulation,  the  extent  of  the  tumor,  and  an  incision  was  made  from  the 
outer  edge  of  the  external  jugular  vein,  over  the  tumor,  to  the  top  of  the  shoul- 
der, the  platysma  m3'oides  and  a  portion  of  the  trapezius  divided,  the  bone  ex- 
posed external  to  the  coracoid  process,  and  divided  with  the  chain  saw;  another 
incision  was  made  over  the  tumor  from  the  sternal  extremity  of  the  clavicle  to 
the  termination  of  the  first  incision  at  the  external  jugular  vein;  in  the  subse- 
quent dissection,  owing  to  the  large  size  of  the  tumor,  the  external  jugular  was 
tied,  and  the  outer  portion  of  the  sterno-mastoid  muscle  was  divided;  the  hiKm- 
orrhage  was  excessive.^ 

BONES    OF    THE    LOWER    LIMBS. 

The  lower  limbs  are  employed  in  support  and  progression,  and 
hence  resections  should  be  so  performed  as  to  preserve  stability  of 
the  bones. 

1.  The  phalanges  of  the  toes  may  be  resected  by  the  methods 
1  J.  C.  Warren.  2  y.  Mott. 


Fig.  110. 


THE   OPERATIONS   ON  BONES.  131 

givi-n  for  the  corresponding  bones  of  the  fingers.  Resection  of  the 
shaft  of  a  phahmgeal  bone  may  be  by  a  straight  incision  on  the  <lor- 
sum,  the  extensor  tendon  being  drawn  aside;  or  the  incision  may  be 
on  the  lateral  surface  of  the  joint  and  curved  downwards  ;  the  bone 
may  be  divided  with  the  forceps.  The  great  toe  is  of  the  utmost 
value  in  progression,  and  in  removing  diseased  bone  every  effort 
must  be  made  to  retain  periosteum,  with  a  view  to  the  preservation 
of  its  function. 

2.  The  metatarsal  bones  may  be  partially  or  entirely  removed. 
{(i.)  In  re>ectiuii  of  the  j)lialani:eal  extremity  of  the  metatarsal 
bones,  make  a  straight  incision  on  the  dors^uin  of  the  toe,  over  the 
part  to  be  removed,  avoiding  the  extensor  temlons,  divide  the  bone 
witli  forceps  or  saw,  and  disarticulate;  in  operating  upon  the  first 
and  fifth,  the  incision  may  be  upon  the  free  lateral  surface,  and  it 
may  be  straight,  or  curved.^  Resection  of  the  extremity  of  the  first 
metatarsal  bone  is  made  by  an  incision  on  the  outside  of  the  joint; 
denude  the  bone  to  the  point  at  which  it  is  to  be  cut,  and  saw  it 
perpendicularly  to  its  axis;  then  detach  it  from  the  soft  parts,  pro- 
ceeding from  behind  forwards  and  complete  the  resection  by  sepa- 
rating it  from  the  phalanx.  (6.)  In  resection  of  the  shaft  of  meta- 
tarsal bones,  the  same  incisions  are  practiced  on  this  part  of  the 
metatarsal  bones  as  at  the  exiremities;  in  removing  the  body  of  the 
first  and  fifth,  a  curved  incision  more  completely  exposes  the  bone 
(Fig.  HI);  the  chain  saw  should  be  used  to  divide  the  shaft  of  the 
first  metatarsal  bone,  (c.)  The  resection  of  the  tarsal  extremity  of 
the  metatarsal  bones  requires  the  same  incisions  as  have  been  given 
for  resections  of  the  phalangeal  extremities  of  the  metatarsal  bones. 
The  chief  obstacles  in  the  disarticulation  are  the  interosseous  liga- 
ments which  unite  the  metatarsal  bones  together.  The  incisicm 
should  freely  expose  the  articulation,  and  the  bone  being  divided, 
it  should  be  raised  with  the  forceps,  and  disarticulation  effected  with 
the    j)oint  of   the   knife,      (r/.)   The  y 

resection    of   entire    first   and    fifth  ^^'^ 

metatarsal  bones  requires  a  curved  ^^  ,  ■'"/    ^ 

incision   with    its    convexity   down-         ^^■— ^^^''^"      /•     ^•— •' 
wards  a,  />,  c     (Fig.   Ill),  and   ex-   ^^^^<^^^^<^^f;;^^^hy^ 
tending  beyond  the  articulation;  the     \^''-^^j^'"' 
bone   being  exposed,  the  middle  of  ^^     '^ 

the  shaft  should  be  divided  with  the  ^■'*^-  1^^- 

saw,  and  the  fragments  separately  disarticulate<l.  In  the  removal  of 
the  three  niiiMle  metatarsal  bones,  a  long  straight  incision  should  be 
made,  the  hone  divided  in  its  centre,  and  the  operation  completed  as 
in  the  preceding  case. 

1  E.  Chassaignac. 


132 


OPERATIVE  SURGERY. 


3.  The  tarsal  bones  are  very  liable  to  be  involved  in  the  artic- 
ular inflammations  of  that  region,  or  to  be  separately  affected  by 
caries  ;  in  either  case  they  may  require  removal,  singly  or  in  groups. 
The  results  have  been  in  the  highest  degree  favorable,  both  as  to 
mortality  and  the  usefulness  of  the  limb.  These  operations  have 
never  been  performed  according  to  any  prescribed  rules,  but  each 
operator  has  adapted  his  incisions  to  the  exigencies  of  the  individual 
case  in  hand  ;  in  many  cases  the  bones  have  not  been  resected 
entire,  but  the  portion  of  bone  diseased  has  been  removed  with  a 
gouge.  Tn  the  resection,  care  should  be  taken  not  to  involve  the 
synovial  membrane  of  adjacent  articulations,  which  do  not  commu- 
nicate with  the  joint  involved;  and,  whenever  practicable,  the  peri- 
osteum should  be  preserved.  The  individual  bones  may  be  resected 
by  the  following  methods,  and  by  a  combination  of  these  incisions 
two  or  more  bones  may  be  removed  at  a  single  operation. 

1.  The  cuneiform  or  wedge  bones  are  placed  at  the  fore  part  of  the  tarsus; 
they  articuhite  beliiiid  witli  the  scaphoid,  and  in  front  with  the  metatarsals  of  the 
three  inner  toes;  the  second  bone  is  the  smallest,  and  does  not  reach  as  far  for- 
wards, so  that  the  second  metatarsal  is  more  deeply  set  in  the  tarsus.  Resec- 
tion i  is  as  follows:  Make  an  incision  on  the  outer  side  of  the  foot,  extending 
from  the  centre  of  the  outer  margin  of  the  plantar  surface  of  the  os  calcis  to 
the  middle  of  the  metatarsal  bone  of  the  little  toe,  1,  1  {Fig.  112);  make  an- 
other incision  on  the  inner  side  of  the  foot  from  the  neck  of  the  astragalus  to 
the  middle  of  the  metatarsal  bone  of  the  great  toe,  1,  1  (Fig.  113);  carefully 


Fig.  112. 


Fig.  11-3. 


dissect  off  the  dorsal  and  plantar  surfaces  from  the  outer  and  inner  sides  until 
the  bones  to  be  removed  are  completely  exposed,  the  thumb  of  the  left  hand 
being  the  guide  to  the  point  and  edge  of  the  knife  in  keeping  close  to  the  surface 
of  the  bones,  and  avoiding  injury  to  the  important  structures  contained  in  the 
soft  parts;  insert  between  the  soft  parts  and  the  bones  a  curved  probe-pointed 
bistoury  across  the  line  of  articulation  between  the  astragalus,  scaphoid,  cal- 
caneum,  and  cuboid,  first  upon  the  dorsal,  then  upon  the  plantar  surface,  and 
open  up  these  joints;  now  introduce  a  key -hole  saw  between  the  plantar  soft 
parts  and  the  shafts  of  the  metatarsal  bones  and  cut  them  through,  the  handles 
of  forceps  or  other  body  being  inserted  between  the  metatarsal  bones  and  the 
dorsal  soft  parts  to  protect  tiie  latter.  The  wound  must  be  tirmly  plugged  with 
pledgets  of  lint,  and  the  foot  supported  with  properly  applied  splints. 
2.  The  cuboid  is  situated  on  the  outer  side  of  the  tarsus,  wedged  in  between 

1  P.  H.  Watson. 


THE   OPERATIONS   ON  BONES. 


133 


the  OS  calcis  ainl  fourth  and  lifth  metatarsal  bones:  internally  it  articulates  with 
the  third  cuneiform  equally  with  the  scaphoid;  the  inferior  surface  is  grj)Oved 
for  the  tendon  of  the  peroneus  lonj^us.i  Kesect  as  follows:  Make  two  incisions, 
3,  3  (Fig.  112),  one  from  the  posterior  extremity  of  the  fifth  metatarsal  backward 
about  two  inches,  the  other  of  the  same  length  from  the  same  point  along  the 
dorsum  inclining  slightly  forwards:  raise  this  fla|),  and  drawing  aside  the  ten- 
d<ins  of  the  peroneus  iongiis  and  brevis,  open  the  joints,  and  raise  the  bone 
with  strong  duck-bill  forceps  introduced  from  the  free  margin. 

3.  The  scaphoid  presents  posteriorly  a  concave  surface,  as  part  of  the  socket 
of  the  head  of  tiie  astragalus,  anteriorly  it  has  three  facettes  for  the  three  cunei- 
form bones,  externally  it  has  a  small  facette  for  the  cuboid,  and  internally  it 
presents  a  free  surface  having  a  small  tubercle. l-  Resect  thus:  Recognizing 
the  tubercle,  make  a  curved  incision,  the  convexitj'  downwards,  extending 
from  one  inch  posteriorly  to  the  same  distance  anteriorly,  2,  2  (Fig.  112);  raise 
this  flaj),  and  separate  the  soft  tissues  from  both  surfaces  of  the  bone;  with  a 
strong  knife,  separate  the  joints  anteriorly  and  posteriorly;  seizing  the  bone 
with  strong  duck-bill  forceps,  raise  and  depress  the  bone,  meantime  detaching 
the  ligaments  with  the  knife. 

4.  The  astragalus  has  most  important  connections;  above  it  articulates  with 
the  tibia,  laterally  with  the  malleoli,  and  below  with  the  calcaneum  by  two  sur- 
faces. It  is  attached  to  the  calcaneum  by  the  interosseous,  posterior,  and  ex- 
ternal ligaments;  and  to  the  scaphoid  by  a  ligament  passing  from  its  anterior 
extremity.  Resection  may  be  made  with  slight  injury  to  the  tendons  which  pass 
over  that  region  or  by  their  destruction.  The  former  methods  are  very  tedious, 
but,  unless  sloughing  occurs,  give  the  best  results.  Resection  is  as  follows:  Make 
a  superlicial  incision'-^  from  the  tendon  of  the  tibialis  anticus,  curved  forwards 
and  outwards  to  the  middle  of  the  sca|)lioid,  thence  backwards  to  a  point  below 
the  external  nvilleolus;  raise  the  tendons  and  draw  them  aside,  except  the  ex- 
tensor brevis  which  should  be  cut:  expose  the  bone,  seize  it  with  forceps,  sep- 
arate its  attachments  with  the  point  of  the  knife,  while  the  foot  is  strongly 
inverted.  By  the  latter  method,  proceed  as  follows  3;  Make  a  curved  incis- 
ion from  one  malleolus  to  the  other;  lay  the  ankle  joint  freely  open,  exposing 
the  whole  upper  part  of  the  diseased  bone;  sever  the  ligaments  attaching  it  to 
the  scaphoid;  raise  the  bone  with  a  lever,  and  divide  the  interosseous  ligament 
uniting  it  to  the  os  calcis;  clear  the  back  part  of  the  bone  caretully  to  avoid 
injury  to  the  tendons  and  vessels  which  lie  near. 

5.  The  OS  calcis  has  been  frequently  removed,  and  with  marked  success, 
as  regards  the  mortality;  the  part  remains  very  useful  for  walking  and  stand- 
ing.■*  The  bone  articulates  above  with  the  astragalus  by  two  articular  surfaces 
having  an  interosseous  ligament;  in  front  with  the  cuboid,  to  which  it  is  lirnil}' 
bound  b_v  four  ligaments,  two  |)Iantars,  which  are  very  strong,  a  dorsal  and  in- 
terosseous. Resection  has  been  made  by  numerous  methods,  but  the  plantar 
flap  (Fig.  114)5  gives  ready  access  to 
the  bone,  and  removes  the  cicatrix  from 
the  {)lantar  surface.  The  patient  lying 
upon  his  face,  make  a  horse-shoe  incis- 
ion;  carry  it  from  a  little  in  front  of  the 
calcaneo-cuboid  articulation  around  the 
heel,  along  the  sides  of  the  foot,  to 
a  corresponding  point  on  the  opposite  side  ;  dissect  up  the  elliptic  flap  thus 
formed,  the  knife  being  carried  close  to  the  bone,  and  thus  expose  the  whole 

1  L.  Holden.     -'  l.  Oilier.     «  T.  Holmes.     <  M.  Polaillon.     s  J.  E.  Erichsen. 


Fig.  114. 


134 


OPERATIVE  SURGERY. 


under  surface  of  the  os  calcis;  then  make  a  perpendicular  incision  about  two 
inches  in  length  behind  the  heel  tlirough  the  tendo-acliillis  in  the  mid  line  and 
into  the  horizontal  one;  detach  the  tendon  from  its  insertion,  and  dissect  up  the 
two  lateral  Haps,  the  knife  being  kept  close  to  the  bones  from  which  the  soft 
parts  are  well  cleared;  then  carry  the  Ijlade  over  the  upper  and  posterior  part 
of  the  OS  calcis,  open  the  articulation,  divide  the  interosseous  ligaments,  and 
then  by  a  few  touches  with  the  point,  detach  the  bone  from  its  connections  with 
the  cuboid.  Or,  make  an  incision  down  to  the  bone  from  the  inner  edge  of  the 
tendo-Achillis  horizontally  forwards  along  the  outer  side  of  the  foot,  somewhat 
in  front  of  the  calcaneo-cuboid  joint,  midway  between  the  outer  malleolus  and 
the  end  of  the  fifth  metatarsal;  it  should  be  on  a  level  with  the  upper  border  of 
the  OS  calcis;  make  a  second  incision  vertically  across  the  sole  of  the  foot  from 
the  anterior  end  of  the  former  incision  to  the  outer  border  of  the  grooved  or 
internal  surface  of  the  os  calcis. 

4.  The  fibula  may  be  resected  in  whole  or  in  part  with  the  best 
results. 

(a.)  The  lower  extremity  articulates  through  the  malleolus  exter- 
nus  with  the  astragalus;  it  also  articulates  with  the  tibia  by  a  convex 
surface,  the  joint  being  continuous  with  that  of  the  ankle. 

The  ligaments  are,  the  interosseous,  which  passes  between  the  two  bones,  and 
is  continuous  above  with  the  interosseous  membrane;  a  flat  triangular  band  ex- 
tending between  the  two  bones,  anteriorly;  the  inferior  ligament  occupying  the 
same  position  posteriorly;  the  transverse  ligament  extending  from  the  external 
malleolus  to  the  tibia. 


Resect  thus  (Fig.  115) 


Fig.  115. 
communicates  with  thi 


Make  a  straight  incision  over  the  bone 
the  entire  length  of  the  diseased  part; 
separate  the  periosteum,  pass  the  chain 
saw,  and  divide  bone;  seize  the  frag- 
ment with  the  forceps,  and  resect. 

(b.)  The  shaft  of  the  fibula  gives  at- 
tachment to  muscles  by  all  its  surfaces, 
and  by  its  internal  border  to  the  in- 
terosseous membrane;  expose  the  bone 
by  a  straight  incision,  pass  the  chain 
saw,  and  divide  the  shaft  at  proper 
points  above  and  below  the  disease. 

(c.)  The  upi)er  extremity  of  the  fib- 
ula articulates  with  the  external  part  of 
the  head  of  the  tibia;  this  articulation 
knee-joint. 


Its  ligaments  are  the  anterior  superior  ligament,  two  or  three  flat  bands, 
which  pass  obliquely  upwards  from  the  head  of  the  tibula  to  the  outer  tuberosity 
of  the  tibia,  and  the  posterior  superior  ligament,  a  single  thick  and  broad  band 
which  passes  from  the  back  i)art  of  the  head  of  the  tibula  to  the  back  part  of 
the  outer  tuberosity  of  the  tibia. 


•      THE   OPERATIONS   ON  BOXES.  135 

The  resection  is  effected  by  the  straiu;lit  iiici>ion;  divide  the  Imne 
with  the  chain  saw,  raise  the  diseased  |)art  with  tlu-  forceps,  and 
tffect  the  resection  with  the  point  of  tlie  knife. 

(<^/.)  in  resection  of  the  entire  (ibida  make  an  incision  parallel  with 
the  l)one  its  entire  length,  separate  the  soft  parts  with  the  periosteum, 
and  divide  the  bone  in  the  centre  vvith  the  chain  saw;  now  disarticu- 
late each  fragment  separately. 

(j.  The  tibia  is  siil)ji'Cted  to  resection  more  frccpiciitly  than  any 
other  lon;^  hone,  owing  to  its  subcutaneous  situation.  The  results 
are  most  favoral)le,  as  new  bone  is  readily  reproduced  when  the 
periosteum  is  well  preserved. ^ 

The  tiliia  is  l)omid  to  the  fibula  l)v  tlie  following  ligaments:  the  anterior,  a 
flat  band  of  fibres;  tlie  posterior,  soniewiiat  triangular;  the  transverse,  long  and 
narrow,  and  below  the  posterior.  The  internal  lateral  ligament  unites  the  lower 
border  of  the  internal  nialleolus  to  the  astragalus,  os  calcis,  and  scaphoid. 

(a.)  The  lower  extremity  forms  ihe  upper  and  internal  part  of  the 
ankle-joint ;  it  is  closely  invested  with  tendons,  and  upon  its  pos- 
tero-internal  border  the  posterior  tibial  artery  and  nerve  pass  to  the 
foot.  Resection  by  the  subperiosteal  method  of  the  entire  diaphysis 
and  lower  epiphysis  has  resulted  in  reproduction  of  the  bone  removed 
and  a  useful  limb.''^  Make  a  straight  incision  along  the  crest  to  the 
ankle-joint;  saw  the  bone  at  the  requisite  height;  raise  the  bone 
from  its  periosteal  bed  by  carefully  separating  the  periosteum ;  dis- 
lodge the  tendons  from  their  grooves,  divide  the  ligamentous  struc- 
tures, and  complete  resection  by  detaching  the  bone  from  the  articu- 
lation. 

(i.)  The  shaft  of  the  tibia  is  subcutaneous  on  the  anterior  and 
inner  part;  exsection  of  this  portion  is  a  comparatively  simple  opera- 
tion ;  on  the  posterior  part  it  gives  attachment  to  muscles,  and  along 
its  external  border  is  attached  the  interosseous  ligament  connecting 
it  to  the  fibula.  The  operation  will  depend  upon  the  extent  of  the 
disease,  and  the  location  of  the  sinuses  if  the  disease  is  necrosis.  The 
incision  should  be  along  the  subcutaneous  borders  of  the  bone,  and 
extend  beyond  the  diseased  portion;  the  periosteum  should  be  thoi'- 
oughly  separated  from  the  shaft,  and  the  bone  divided  with  a  chain 
saw  at  either  extremity;  the  fragment  is  then  easily  separated. 

Or,  make  a  long  curved  incision  in  the  length  of  the  bone,  having  its  convex- 
ity backwards;  dissect  this  flap  up  and  turn  it  outwards;  divide  the  bone  at  tlie 
proper  points,  and  raise  the  fragment  with  forceps.  As  excision  of  the  shaft 
of  the  tiliia  is  generally  undertaken  for  necrosis,  tlie  gouge  is  found  useful  in 
separating  dead  bone,  and  the  mallet  maybe  used  freely;  it  is  also  frequently 
desiralile  to  use  the  trephine. 

(c.)  The  upper  extremity  of  the  tibia  is  broad,  and  presents  upon 
1  L.  Oilier.  2  D.  W.  Cheevers. 


136  OPERATIVE   SURGERY. 

its  upper  surface  two  cup-sbaved  cavities  for  articulation  with  the 
condyles  of  the  femur. 

The  ligaments  which  are  attached  to  it  are,  anteriorly,  the  ligamentum  pa- 
telhe,  internally,  the  internal  lateral,  posteriorly,  the  posterior  ligament,  or  the 
ligamentum  posticum  Winslovvii,  and  within,  the  anterior  and  posterior  crucial 
ligaments. 

The  operative  process  is  entirely  subordinated  to  the  degree,  actual 
situation,  and  form  of  the  disease  ;  so  that  there  may  be  occasion  for 
the  crucial,  or  the  elliptical,  or  simple  incision,  and  also  for  a  va- 
riety of  saws  and  bone-cutting  instruments.^  When  practicable, 
subperiosteal  resection  should  always  be  performed. 

7.  The  patella,  though  in  immediate  relation  with  the  knee-joint, 
may  be  excised  with  good  results.  Make  a  crucial  incision,  the  trans- 
verse branch  being  over  the  base  of  the  bone,  or  a  second  transverse 
incision  may  be  made  near  the  ape.x;  dissect  the  flaps  off  cautiously, 
and  remove  the  bone  or  its  fragments;  the  tendinous  expansion  sur- 
rounding the  bone  should  be  separated,  and  not  divided,  as  far  as 
possible.     The  antiseptic  method  should  be  strictly  pursued. 

7.  The  femur  is  the  largest  bone  of  the  skeleton.  Resections  of 
different  portions  of  the  bone  are  very  frequent  and  give  satisfactory- 
results,  especially  when  the  periosteum  is  i^reserved,  as  new  bone  is 
reproduced.^ 

(a.)  The  lower  extremity  is  rarely  removed,  except  in  exsections 
of  the  knee-joints.  When  it  is  necessary  to  operate  for  necrosis  in 
this  region,  the  sinuses  are  the  safest  guides  to  the  dead  bone.  If, 
however,  a  formal  operation  is  required,  make  a  long  straight  or 
slightly  curved  incision  on  the  external  aspect  of  the  knee,  isolate 
the  femur  a  little  above  the  condyles,  preserving  the  periosteum,  and 
make  section  of  the  bone  by  the  chain  saw;  the  fragment  is  then 
made  to  protrude  at  the  wound,  seized  with  forceps,  and  disarticu- 
lated. 

(b.)  The  shaft  of  the  femur  gives  attachment  to  muscles  thi-ough- 
out  nearly  its  entire  extent,  and  to  reach  it  without  injury  to  the  soft 
parts,  the  muscular  septa  must  be  followed,  either  along  the  antero- 
external  region  of  the  limb,  or  as  indicated  by  the  seat  of  the  disease; 
the  curved  incision  and  the  semilunar  flap  raised  up  from  without 
inwards,  and  from  behind  forwards,  m.ay  sometimes  be  necessary  to 
lay  bare  the  bone  to  a  sufficient  extent.  The  limb  must  be  well 
supported  by  the  gypsum  or  other  dressing  during  the  after  treatment. 

(c.)  The  trochanter  major  gives  attachment  to  the  gluteus  niedius 
anil  minimus,  and  by  its  fossa  to  the  external  rotators.  In  resection 
make  a  free  crucial  incision  through  the  skin  nnd  tendon  of  the  glu- 
teus maximus,  and  when  the  surface  is  sufficiently  exposed,  use  the 

1  A.  Velpeau.  2  T.  Holmes;  J.  Bell. 


THE   OPERATIONS   ON  BONES.  137 

gouge  to  ?coop  away  the  affected  parts;  if  the  disease  prove  exten- 
sive, divide  the  attachments  of  the  ghitei  to  the  upper  anil  fore  [t&ri 
of  the  process,  and  then  remove  the  entire  trochanter  with  saw  and 
forcejjs. 

{d.)  The  upper  extremity  of  the  femur  enters  so  largely  into  the 
exsections  of  the  hip-joint  that  the  methods  of  removal  are  essen- 
tially the  same. 

BONES    OF    TIIK    TRUNK. 

The  bones  of  the  trunk  form  the  walls  of  cavities  containing  vital 
organs,  and  give  support  to  the  limbs;  resections  are,  therefore,  gen- 
erally partial,  and  must  be  performed  with  such  care  and  by  such 
methods  as  will  not  impair  these  functions. 

1.  The  vertebrae  have  been  subjected  to  frequent  partial  resec- 
tions. The  removal  of  loose  fragments  after  severe  injuries,  as  from 
shot,  are  perfectly  rational,  and  have  resulted  in  a  fair  measure  of 
success.^  Resections  of  the  arches  or  trephining  the  spine,  is  one  of 
the  most  diflicult'^  and  fatal  operations  in  surgery,  and  practically 
■without  benefit.  Eighty-five  per  cent,  of  terminated  cases  have 
proved  fatal,  and  there  is  no  well  authenticated  case  of  complete  re- 
covery.8  The  conclusion  is  inevitable  that  without  much  more  posi- 
tive favorable  evidence,  resection  of  the  arch  cannot  be  accepted  as 
an  established  operation.^ 

If  resection  is  attempted,  proceed  with  the  operation  as  follows :  *  make  a 
long  incision  above  tlie  rid<;e  of  the  spinous  processes,  tlie  middle  of  which  is 
opposite  the  displacement;  divide  all  the  attaciiments  of  the  muscles  to  the  ar- 
ticular processes;  as  one  end  of  eacli  muscular  bundle  is  separated  from  its 
nttacimient,  it  retracts  and  needs  little  iioldiiig  back;  the  saw  or  tlie  nippers  are 
generally  sulHcient  io  divide  tlie  vertebral  arch;  in  sawing  or  cutting  out  the 
arcli,  grasp  the  spinous  process,  if  it  be  not  broken,  with  a  pair  of  stout  tooth 
forceps,  which  are  to  be  preferred  to  the  elevator  for  lifting  the  detached  bone 
from  its  natural  connections;  a  small  crowned  trephine  may  be  used  to  cut 
through  the  vertebral  arch,  or  IIe3''s  saw. 

2.  The  sacrum  may  bo  partially  resected  for  the  relief  of  pressure 
upon  nerves  as  follows:  Make  a  crucial  incision;  remove  the  spinous 
process  of  the  bone  with  forceps  and  Iley's  saw;  apply  a  trephine, 
and  make  an  opening,  through  which  introduce  bone  nippers,  and  re- 
move the  bone.^ 

.3.  The  coccyx  may  be  excised  in  whole  or  part  for  necrosis, 
fracture,  and  a  painfid  affection,  coccydinia,  thus:  place  the  patient 
on  the  side,  the  thighs  flexed,  and  the  hips  close  to  the  edjje  of  the 
bed;  the  buttocks  being  separated,  make  an  incision  in  the  median 
line,  extending  from  the  extremity  of  the  coccyx   upwards  to  the 

1  G.  A.  Otis.  2  p.  F.  Eve.  »  J.  Ashurst,  Jr.  *  J.  F.  South. 

5  G.  C.  Blackmaa. 


138  OPERATIVE  SURGERY. 

requisite  extent;  remove  the  diseased  bone  either  with  the  gouge,  or 
the  drill,  or  the  bone  may  be  divided  with  the  cutting  forceps.  The 
forefinger  in  the  rectum  determines  the  progress  and  extent  of  the 
resection. 

4.  The  ribs  are  closely  invested  on  their  internal  surface  by  the 
pleura,  and  along  the  groove  on  the  lower  border  runs  the  intercostal 
artery.  The  only  admissible  primary  interference  when  the  ribs 
are  fractured  by  balls  is  the  extraction  of  loose  fragments,  and 
the  smoothing  off  of  sharp- pointed  ends.^  Resection  for  necrosis 
should  be  made  by  opening  existing  sinuses  and  carefully  separating 
the  thickened  periosteum  with  the  pleura.  In  the  removal  of  mor- 
bid growths,  portions  of  ribs  may  require  resection;  great  care  must 
be  taken  to  separate  the  pleura  with  the  periosteum  without  wound- 
ing the  former.  Proceed  as  follows :  Place  the  patient  upon  the 
sound  side,  and  expose  the  bone  by  an  incision  along  the  middle  of 
the  rib,  or  the  incision  may  be  curved  downwards;  divide  the  inter- 
costal muscles  and  disengage  the  intercostal  artery  from  its  groove 
in  the  inferior  border  of  the  bone;  separate  the  pleura  cautiously 
with  the  handle  of  the  scalpel,  or  similar  instrument,  and  pass  a 
thin  piece  of  pas-teboard  or  other  substance  behind;  divide  the  bone 
with  the  chain  saw.  Section  of  the  posterior  part  of  the  rib  may 
be  first  made  to  avoid  wounding  the  pleura;  scrape  carefully  each 
border  of  the  bone,  and  do  not  incline  the  point  of  the  knife  tow- 
ards the  intercostal  space.  In  removing  the  false  ribs,  support  the 
free  extremity  while  the  rib  is  divided  posteriorly. 

Or,  make  a  curved  incision  having  its  convexity  downwards,  exposing  the 
diseased  bone,  two  ov  tliree  days  before  resection;  after  iiaving  cut  the  flap  pass 
two  threads  firmly  united,  by  means  of  a  curved  needle  along  the  internal  face 
of  the  rib  at  the  point  where  the  bone  is  to  be  divided;  replace  these  threads  after 
twelve  or  twentv-four  hours  bj' a  drainage  tube;  these  tubes  prepare  the  way 
for  the  passage  of  the  chain  saw;  on  the  second  or  third  day  saw  the  bone  and 
remove  the  fragment.'^ 

5.  The  sternum  has  been  frequently  partially  resected  for  shot 
injuries,  and  with  very  favorable  results,  the  mortality  being  very 
slight.^  When  subperiosteal  resection  has  been  made  for  necrosis, 
new  bone  has  been  reproduced.*  The  incision  for  resection  may  be 
crucial  or  vertical,  according  to  extent  of  injury  or  disease,  and  the 
parts  may  be  removed  by  the  trephine,  gouge,  or  forceps. 

BONKS    OF    THE    FACE. 

In  resection  operations  on  the  bones  of  the  face  it  is  important  to 
avoid,  as  far  as  possible,  incisions  which  will  leave  unsightly  scars, 
and  the  removal  of  bones  which  destroy  the  symmetry  of  the  fea- 
tures.    When   practicable,  perform  intra-buccal  resections  without 

1  G.  A.  Otis.  2  E.  Chassaignac.  3  Q.  Heyfelder.  *  L.  Oilier. 


THE   OPKRATIOXS   ON  BOXES.  139 

external  ineiiiion;  ^  make  incisions  along  tlie  natural  folds  of  skin  ami 
preserve  the  borders  of  the  mouth  from  division  ;2  in  all  cases  that 
admit  of  ^ul)])*  ri(jsteal  resection,  tliis  method  is  to  he  preferred. 

1.  The  inferior  maxilla  is  very  liable  to  injury  and  necrosis,  and 
to  be  the  seat  of  morbid  growths.  In  comminuted  fractures  the  frag- 
ments shoulil  be  preserved  unless  quite  detachetl,  as  they  have  great 
vitality,  and  are  important  in  the  preservation  of  the  contour  of  the 
jaw.  For  necrosis  the  resection  should  as  far  as  possible  be  sub- 
periosteal and  intra-buccal,  and  both  objects  may  often  l)e  accom- 
plished by  occasionally  aiding  the  slow  process  of  separation  of  the 
necrotic  bone  from  its  attachments  to  bone  and  periosteum  with 
the  elevator,  or  the  handle  of  the  scalpel,  or  a  spatula.^  By  de- 
grees the  sequestrum  is  loosened,  new  bone  forms  around  it  from 
the  periosteum,  and  eventually  the  dead  bone  may  be  lifted  from  its 
bed  with  perhaps  slight  incisions  of  the  gum;  by  this  method  large 
portions  of  the  jaw,  and  even  the  entire  jaw,  may  be  reproduced 
during  the  process  of  sequestration,  and  not  only  its  contour  but  its 
funetion  be  preserved.^  This  method  is  preferable  to  early  resec- 
tion, which  is  liable  to  be  followed  by  great  contraction  of  the  parts, 
even  if  the  periosteum  is  preserved  and  new  bone  is  produced. "  In 
resection  for  tumors  ample  external  incisions  are  often  required, 
and  large  portions  of  the  bone  must  be  sacrificed.  But  small  tu- 
mors, involving  only  the  alveolus,  may  be  removed  with  bone  forceps 
without  incision  of  the  skin.'*  A  considerable  portion  of  the  central 
part  of  the  jaw  may  be  removed  without  incising  the  lip,  if  the  mu- 
cous membrane  is  freely  divided  between  it  and  the  bone,  and  the  lip 
is  drawn  well  down.* 

(a.)  When  the  entire  central  part  is  to  be  resected  proceed  as  fol- 
lows :  Pass  a  stout  ligature  through  the  tip  of  the  tongue  to  hold  it  in 
position  when  the  muscles  are  incised;  an  assistant  standing  behind 
the  patient  holds  his  head  firmly,  and  compresses  the  two  facial 
arteries  at  the  points  where  they  cross  the  lower  jaw;  standing  in 
front,  seize  with  the  left  hand  one  of  the  angles  of  the  loAver  lip, 
while  an  assistant  holds  the  other  angle  from  the  bone,  and  the 
whole  in  a  state  of  tension;  divide  the  lip  with  a  vertical  incision 
through  the  median  line  down  to  the  os  hyoides;  or,  if  practicable, 
make  a  single  curve<l  incision  along  the  lower  margin  of  the  jaw ; 
raise  the  periosteum  from  the  bone  to  be  removed;  extract  a  tooth 
opposite  to  each  point  where  bone  is  to  be  sawn  through  ;  use  a 
small  Hey's  saw,  or  the  chain  saw  ;  the  bone  being  sawn  through  on 
both  sides,  divide  the  muscles  attached  to  it,  as  closely  as  possible 
to   their   insertion,  carrying  the   knife   along   the   concave   surface. 

1  .1.  R.  Wood.  -  Sir  W.  Fergusson.        8  Von  Langen beck;  M.  Rizzoli. 

*  C.  Heath. 


140  OPERATIVE  SURGERY. 

Unite  the  two  flaps  with  silver  wire  sutures  passed  through  to  the 
mucous  membrane  adjusting  the  margins  of  the  lip;  or  use  the  hare- 
lip pins  with  figure-of-eight  suture,  if  there  is  much  tension;  at- 
tach the  ligature  holding  the  tongue  to  a  fold  of  adhesive  strip  firmly 
fastened. 

Commence  the  incision  at  the  angle  of  the  mouth  opposite  the  healthy  portion 
of  jaw  ;  extend  it  down  to  the  place  at  which  the  saw  is  to  be  applied ;  then 
along  the  base  of  the  jaw  past  the  middle  line  to  the  other  point  of  section. i 

(i.)  The  horizontal  portion  has  the  following  anatomical  parts  to  be 
considered:  — 

Attached  on  its  internal  surface  is  the  mylo-hj'oideus  muscle,  beneath  which 
is  the  fossa  for  the  submaxillary  gland  ;  on  its  external  surface  along  its  lower 
margin  is  the  attachment  of  the  platysma  myoides  muscle,  and  along  its  alve- 
olar margin  the  buccinator;  the  facial  artery  mounts  over  its  lower  border,  just 
anterior  to  the  insertion  of  the  masseter  muscle. 

Resect  as  follows :  ^  Make  an  incision  commencing  behind  and  a 
little  above  the  angle,  avoiding  the  facial  nerve  and  parotid  duct 
along  the  border  of  the  jaw,  terminating  from  a  quarter  to  half  an 
inch  below  the  symphisis  menti ;  raise  and  reflect  the  flap  on  the 
face,  tying  both  ends  of  the  divided  facial  artery;  the  bone  being 
denuded,  or  the  periosteum  raised,  divide  with  a  chain  saw  passed 
at  the  proper  point  anteriorly,  a  tooth  being  removed  if  necessary; 
seize  the  end  of  the  fragment  with  strong  forceps,  and  divide  with 
the  chain  saw  at  or  near  the  angle,  as  may  be  required;  close  the 
wound  firmly  with  silver  wire  sutures,  care  being  taken  to  compress 
the  surfaces  of  the  incised  mucous  membrane  closely  to  secure 
prompt  union. 

(c.)  The  half  of  the  lower  jaw  has  the  following  additional  rela- 
tions:— 

The  rami  terminate  in  two  processes,  one  for  articulation,  and  the  other  to 
give  attachment  to  the  temporal  muscles;  the  articulation  is  supported  by  an 
external  and  internal  lateral  ligament,  and  the  capsular;  the  stylo-maxillary 
passes  from  the  styloid  process  to  the  angle  of  the  jaw;  the  internal  maxillary 
ar'ery  passes  behind  the  neck  of  the  condyle  in  such  proximity  as  to  render 
care  necessary  to  avoid  wounding  it  in  disarticulation  of  the  jaw. 

Resect  as  follows  (Fig.  116):  Place  the  patient  with  the  shoulders 
raised  and  head  turned  to  the  opposite  side;  coiumence  the  incision 
at  the  zygomatic  arch  behind  the  condyle,  carry  it  downwards  be- 
hind the  ramus  to  the  angle,  and  under  the  body  of  the  bone  to  a 
point  one  quarter  of  an  inch  below  the  symphisis  nienti  if  the  oper- 
ation is  for  an  old  necrosis,^  but  through  the  centre  of  the  lip  (Fig. 
116),  if  for  the  removal  of  bone  for  other  affections;  in  the  former 
case  incise  the  periosteimi  and  raise  it  from  the  bone  throughout, 
1  J.  Bell.  2  J.  R.  Wood. 


THE   OPERAriOSS   ON  BONES. 


141 


but  otherwise  for  tlie  rouKjviil  of  a  tumor  ;  ^  the  facial  artery  must 
be  cautiously  divided  and  seciu'ed  ;  sub-periosteal  resectiuu  may  now 
be  rapidly  performed  for  necro- 
sis, the  bone  beinfj  divided  with 
the  chain  or  small  straight  back 
saw,  and  tlie  cut  end  used  as  a 
lever  to  raise  it  from  its  position 
during  the  process  of  enuclea- 
tion ;  if  tlie  periosteum  is  not 
saved,  having  divided  the  bone 
rf,  seize  the  cut  extremity,  with 
forceps,  raise  it  from  its  bed, 
carefully  separating  all  tissues 
adherent  to  the  body  and  ra- 
mus ;  carry  a  probe  pointed 
bistoury  or  curved  scissors  beneath  the  zygomatic  arch,  and  behind 
the  coronoid  process,  and  with  it  divide  the  tendon  of  the  temporal 
muscle  while  dein-essing  the  bone  to  disengage  the  process  and  luxate 
the  condyle;  pull  the  !)one  c,  strongly  outwards,  as  far  as  possible 
from  the  vessels,  in  order  to  avoid  especially  the  internal  maxillary 
artery,  e,  and  complete  the  operation  by  dividing  the  pterygoid 
muscles  and  the  articular  ligaments.  Secure  every  bleeiling  vessel, 
and  close  the  wound  by  carefully  adjusting  the  margins  of  the  integ- 
ument and  of  the  mucous  membrane. 

When  the  tumor  is  large  and  completely  wedged  in  the  upper  part  of  the  bone 
so  as  to  hinder  the  fieeing  of  the  coronoid  ]>roc('ss,  and  prevent  dislocation,  cut 
oft"  the  tumor  as  liigh  as  possible  with  the  bone  forceps  or  saw,  and  then  remove 
the  remaining  portion  of  the  jaw  only  in  case  the  disease  Is  malignant. i 

(f/.)  The  entire  lower  jaw  is  removed  as  follows:  Pass  a  ligature 
through  the  anterior  part  of  the  tongue,  and  intrust  to  an  assistant ; 
make  an  incision  commencing  opposite  the  left  condyle  downwards 
towards  the  angle  of  the  jaw,  ranging  at  about  two  lines  in  front  of 
the  posterior  border  of  the  ramus,  thence  along  the  base,  to  termi- 
nate at  the  median  line  a  little  ])ostcrior  to  the  most  prominent  part 
of  the  l)order  of  the  jaw.  Dis.sect  -  upwards  the  tissues  of  the  cheek, 
and  reflect  downwards,  for  a  short  distance,  the  lower  edge  of  the 
incision;  separate  the  tissues  forming  the  floor  of  the  mouth,  situated 
upon  the  inner  surface  of  the  body  of  the  bone,  from  their  attach- 
ments from  a  point  near  the  median  line,  as  far  back  as  the  angle  of 
the  jaw;  next  divide  the  attachments  of  the  buccinator  ;  secure  by 
ligature  the  facial  artery,  the  sub-mental  and  the  sub-lingual;  expose 
the  external  siu-face  of  one  branch  of  the  jaw,  and  of  tlie  temporo- 
maxillary  articulation,  by  dissecting  the  masseter  upwards  as  far  as 
1  C.  Heath.  2  J.  M.  Carnochan. 


142  OPERATIVE  SURGERY. 

the  zygomatic  arcli;  seize  the  ramus  and  pull  the  coronoid  process 
downwards  below  the  zygoma;  divide  the  insertion  of  the  ptery- 
goiileus  internns,  grazing  the  bone  in  doing  so;  carefully  avoid  the 
lingual  nerve,  here  in  close  proximity;  divide  the  dental  artery  and 
nerve;  separate  the  tissues  attached  to  the  inner  face  of  the  bone, 
as  high  up  as  a  point  situated  about  a  line  below  the  sigmoid  notch, 
between  the  condyle  and  the  coronoid  process;  detach  the  tendon  of 
the  temporal  muscle  by  means  of  blunt  curved  scissors,  a  probe- 
pointed  bistoury  keeping  close  to  the  bone;  make  use  of  the  ramus, 
now  movable,  as  a  lever  to  aid  in  the  disarticulation  of  the  bone; 
to  effect  safely  the  disarticulation  of  the  condyle,  penetrate  the  joint 
by  cutting  the  ligaments  fi'om  before  backwards  and  from  without  in- 
wards; the  articulation  thus  opens  sufficiently  to  allow  the  condyle  to 
be  completely  luxated;  bliuit  scissors  may  now  be  used  to  cut  care- 
fully the  internal  part  of  the  capsule,  and  the  maxillary  insertion  of 
the  external  pterygoid  muscle;  by  a  slow  movement  of  rotation  of 
the  ramus  u])on  its  axis  the  cond\le  is  detached  and  the  operation 
completed.  To  effect  the  removal  of  the  other  half,  malce  the  same 
incision  on  the  opposite  side,  so  as  to  meet  the  first  on  the  median 
line  ;  the  dissection  is  similar. 

2.  The  superior  maxilla  has  the  following  important  anatomical 
features : ^  — 

It  is  attaclied  to  other  bones  in  but  three  principal  points:  first,  by  its  as- 
cending process  and  articulations  with  the  os  unguis  and  ethmoid;  second,  by 
the  orbital  border  of  the  malar,  as  far  as  the  spheno-maxillary  fissure;  third, 
b\'  the  articulation  of  the  two  maxillary  bones  with  each  other  and  palate  bone; 
there  is  a  fourth  point  of  contact  behind  with  tiie  pterygoid  process  and  palate 
bone,  whicii  yields  easily  b}'  simple  depression  of  the  maxillary  bone  into  the 
interior  of  tlie  mouth;  in  attacking  these  different  points  no  large  vessel  is  in- 
jured; the  trunk  of  the  internal  maxillary  artery  maj'  be  easily  avoided,  or  in 
any  case  tied  after  the  removal  of  the  bone;  moreover,  in  case  of  imforeseen 
haemorrhage  during  the  operation  we  have  a  resource  in  compression  of  the  car- 
otid; only  one  important  nerve  trunk,  the  superior  maxillary,  need  be  divided. 

Resection  of  the  bone  is  performed  for  the  extirpation  of  malig- 
nant growths  and  to  gain  access  to  naso-pharyngeal  tumors  ;  in  the 
former  case  it  is  justifiable,  only  where  the  disease  is  limited  to  the 
upper  jaw  and  its  corresponding  palate  bone,  owing  to  the  certainty 
of  recurrence  if  the  disease  extends  beyond. ^  The  methods  of  pro- 
cedure are  numerous,  and  give  great  and  desirable  latitude  ^  to  the 
operator.  ICarly  operators  cut  boldly  through  the  cheek, ^  1  (Fig. 
118),  but,  to  avoid  unsightly  scars,  the  rule  now  obtains  of  making 
the  incision  in  the  course  of  natural  folds  of  the  skin,  2  (Fig.  118)^, 
and  2 5  and  4^  (Fig.  117).     Subperiosteal  resection  may  be  made  by 

1  J.  F.  Malgaigne.  2  j.  Bell.  8  Sir  W.  Fergusson.  *  Lizars. 

6  E.  Nelaton.  6  A.  Guerin. 


THE  OPERATIOXS  ON  BOXES. 


143 


these  incisions,  Ijut  a  more  formal  operation  is  made  by  dividiiur  the 
cheek,  1  (Fig.  117).i 


Fig.  117. 


Fig.  118. 


Resect  the  superior  maxilla  below  the  floor  of  the  orbit  -  (Fig.  119), 
bv  the  following  operation  :  Make  an  incision  slightly  convex  back- 
wards commencing  at  the  ala  of  the  nose,  and  terminating  at  the  cor- 
responding conmiissure  of  the  lip,  following  the  naso-labial  fold  or  fur- 
row, 4  (Fig.  117)  ;  dissect  up  the  two 
flaps  resulting  from  this  incision  until 
the  nostril  is  exposed,  and  the  malar 
process  is  completely  denuded;  with 
a  small  saw  held  in  the  right  hand,  a, 
saw  through  the  malar  process  from 
above  downwards,  and  a  little  from 
within  outwards  ;  the  soft  palate  hav- 
ing been  detached  from  the  posterior 
border  of  the  i)alatine  bone  by  a  trans- 
verse incision  made  at  the  posterior 
border  of  the  last  great  molar,  and  an 
incisor  tooth  having  been  extracted, 
divide  the  horizontal  portion  of  the 
maxilla  from  before  backwards  with 
cutting  forceps  c,  one  branch  being  in 
the  mouth,  and  the  other  in  the  nares; 
make  a  section  of  the  bone  from  the  ^'*^-  ^'''• 

divided  malar  process  to  the  nares  by  the  forceps  b ;  seize  the  bone 
with  strong  forceps,  and  remove,  fracturing  the  ptervsjoid  process. 

The  entire   maxilla  or  portions  may  be  resected  as  follows:  ^  Ex- 
tract the  incisor  teeth  of  tliat  side  ;  divide  the  upper  lip  in  the  median 
line  to  the  nostril ;  continue  the  incision  around  the  ala  and  up  the 
1  L.  OlUer.  2  a.  Guerin.  «  Sir  W.  Ferirusson. 


144  OPERATIVE  SURGERY. 

side  of  the  nose,  towards  the  inner  canthus  of  the  eye,  thence  con- 
tinue it  in  a  slight  curve  below  the  orbit,  2  (Fig.  117  i),  or,  to  the 
malar  bone,  2  (Fig.  118)  ;  reflect  the  skin  from  the  bone,  ami  with  a 
narrow  saw  passed  into  the  nostril  divide  the  alveolus  and  hard  pal- 
ate ;  incise  the  mucous  membrane  of  the  moulh  as  far  back  as  the 
soft  palate  ;  with  a  narrow  saw  passed  into  the  nostril  divide  the 
alveolus  and  hard  palate  ;  cut  partially  also  the  malar  process  of  the 
maxillary  bone,  or,  if  necessary,  the  bone  itself,  and  the  nasal  pro- 
cess of  the  superior  maxilla,  and  complete  the  division  of  these  bones 
with  the  forceps:  grasp  the  bone  with  the  lion  forceps,  and  detach  it 
forcibly  from  the  pterygoid  process  and  palate  bone;  when  the  bone 
is  loose,  raise  the  fascia  of  the  orbital  palate,  separate  the  infra- 
orbital nerve,  the  soft  palate,  and  any  adhering  tissues.  The  haem- 
orrhage must  be  suppressed  by  ligatures  and  the  actual  cautery,  and 
the  wound  adjusted  at  the  lips  by  hare  lip-pins  and  in  other  parts  by 
the  wire  suture. 

Resection  may  be  necessary  by  an  incision  through  the  cheek  2;  Make  an  in- 
cision with  its  convexity  downward,  1  (Fig.  118)  from  the  commissure  of  the 
lips  to  the  temiioral  fossa;  dissect  this  large  flap  from  below  upwards,  and 
turn  it  back  upon  tiie  forehead;  cut  through  with  the  forceps  the  external  or- 
bital process  at  its  juncture  with  the  malar  bone,  the  zygomatic  arch,  the  os 
unguis,  and  the  ascending  nasal  process  of  the  upper  jaw;  divide  the  soft  parts 
which  connect  the  ala  of  the  nose  to  the  maxillary  bone,  and  separate  the  max- 
illae in  front  with  a  chisel  and  mallet,  or  a  small  saw;  detach  the  soft  parts  from 
the  floor  of  the  orbit,  divide  at  once  the  superior  maxillary  nerve,  and  the  con- 
nections of  the  bone  with  the  ptervgoid  process;  conclude  the  operation  by  cut- 
ting through  with  the  bistoury,  or  curved  scissors,  the  velum  of  the  palate,  and 
the  remaining  soft  parts  which  still  adhere  to  and  retain  the  bone.  The  chain 
saw  may  be  used  to  divide  the  processes. 

Resection  without  external  incision  may  be  made  as  follows^:  The 
head  being  thrown  back  in  position,  and  the  mouth  kept  open  by  the 
gag  placed  between  the  back  teeth  of  the  opposite  side,  place  a 
sponge  cut  so  as  to  completely  fill  up  the  passage  to  the  throat,  and 
hold  it  in  position  on  the  soft  palate  by  a  sponge-holder  to  prevent 
the  blood  passing  into  the  throat  during  the  first  part  of  the  opera- 
tion, the  patient  being  allowed  to  breathe  only  through  the  nose  ; 
make  two  internal  incisions  from  behind,  half  an  inch  on  each  side 
of  the  fangs  of  the  molars  forward  to  the  central  incisor  of  the  op- 
posite side  ;  denude  the  periosteum  with  the  elevator  by  commen- 
cing externally  at  the  central  incisor,  and  passing  backward  to  the 
internal  pterygoid  process,  and  upward  to  the  malar  bone;  then  in- 
ternally from  the  same  point  to  and  a  little  past  the  centre  of  .the 
palate  ;  the  sponge  now  being  of  no  further  use,  remove  it;  denude 
the  tensor-palati  muscle  from  its  attachment  to  the  posterior  part  of 

1  E.  Nelaton.        2  a.  Velpeau,  J.  Syme,  R.  Listen.        3  D.  H.  Goodwillie. 


THE   OPERATIONS   ON   BONES. 


14.3 


the  lianl  palate  ;  care  being  taken  not  to  injure  the  posterior  pala- 
tine vessels  and  (lescending  palatiiu^  nerve  that  pass  at  this  j)oint  for- 
ward on  to  the  hard  [);datc  through  the  posterior  foramen  and  along 
H  groove  ;  now  extraet  the  lateral  incisor  of  that  side,  and  by  its 
socket  thongli  a  little  to  the  ri'_dit  of  the  centre  of  the  hard  palate, 
so  as  to  save  the  vomer,  make  a  section  with  a  saw,  dividing  the 
superior  maxillary  bones;  change  this  saw  for  one  much  shorter, 
the  teeth  of  which  have  a  different  angle  and  the  cheek  falls  into 
a  U  shank  which  allows  the  saw  to  play  freely;  make  a  section 
up  between  the  tumor  and  the  internal  pterygoid  process  to  the 
malar  bone,  then  forward  through  the  canine  fossa,  dividing  also 
the  inferior  tubinated  bone,  to  meet  the  other  section  at  the  ala 
nasi  ;  after  the  saw  has  entered  the  antrum  in  this  last  section,  the 
handle  shoidd  be  advanced  more  rajjidly  than  the  point;  this  pre- 
vents tlie  j)oint  from  piercing  the  vomer.  By  these  two  sections  a 
tumor  with  adjacent  bone  may  be  removed  clean. 

3.  The  superior  maxillae  may  be  removed  at  a  single  operation 
liy  an  incision.  .'3  (Fig.  1 1  7),  along  the  centre  of  the  nose  and  through 
the  upper  lip  ;  adilitional  incisions  may  be  made,  if  required,  under 
the  orbit  laterally.  Or,  a  four-cornered  flap  may  be  made  by  an  in- 
cision on  either  side  from  the  angles  of  the  mouth  to  the  external 
angles  of  the  eye,  1  (Fig.  117). 

III.    TKEPHINING. 
This  operation  is  required  for  the  removal  of  a  circular  piece  of 
bone,  as  in  opening  into  cavities  in  bone.     The  instrnmtnts  neces- 
sary are  the   trephine    and  elevator 
(Fig.  1-20).     The  trephine,  h,  c,  d,  i- 
a  cylindrical  saw,  witli  a  cross  handK 
like  a  gimlet,   a,  and   a  centre-pin, 
the  perforator,  around  which   it   re- 
volves until  the  saw  has  cut  a  groove 
sufficient   to  hold  it  ;  the  centre-pin 
is  then  retired.     The  handle  is  fast- 
ened to  the  shaft  by  a  screw,  with 
a  button  affixed  to  the  end    of  the 
shaft;  or  the  screw   may  be  on  one 
end  ;  when  the   handle   is   placed  on 
the    shaft    this    screw    is    tightened.  Fig.  120. 

and  its  extrenuty  reaches  the  shaft  and  fastens  it  firmly  in  its  place; 
the  advantaire  of  this  arrangement  is  that  the  upper  surface  of  the 
handle  is  smooth,  and  the  palm  of  the  hand  is  not  bruised  as  it  is 
by  the  handle  of  the  old  instrument.  The  conical  trephine,  c,  has 
the  peculiar  advantage  of  dividing  the  osseous  walls  without  any 
10 


146  OPERATIVE  SURGERY. 

danijer  of  wounding  the  structures  within.  It  is  a  truncated  cone, 
with  spiral  peripheral  teeth,  and  oblique  crown  teeth;  when  applied, 
the  peripheral  teeth  act  as  wedges  so  long  as  counteracting  pressure 
exists  on  the  crown  teeth;  upon  removal  of  that  pressure  of  the  Viony 
walls  its  tendency  is  to  act  on  the  priiu'iple  of  a  screw;  but  owing  to 
its  conical  form  and  the  spiral  direction  of  its  peripheral  teeth  its 
action  ceases.  In  the  construction  the  trephine  is  made  of  different 
sizes  to  meet  the  various  conditions  in  which  it  is  used,  as  on  the 
cranium,  b,  c,  or  for  opening  the  antrum,  d. 

Trephiniug  is  performed  as  follows:  Make  an  incision  down  to  the 
bone,  having  the  form  of  a  V,  T,  or  -|-,  or  of  a  semicircle;  the  bone 
being  scraped,  take  the  handle  of  the  trephine  in  the  right  hand, 
and  fixing  the  perforator  by  its  screw  so  that  it  protrudes  slightly 
beyond  the  teeth,  place  the  perforator  in  the  centre  of  the  bone  to 
be  removed;  woi'k  the  instrument  alternately  backwards  and  for- 
wards, until  the  teeth  liave  cut  a  groove  sufficiently  deep  to  receive 
them;  then  loosen  the  perforator  and  fix  it  in  the  shaft,  to  avoid 
wounding  the  membranes;  great  care  should  be  taken  to  maintain  the 
instrument  in  a  position  perpendicular  to  the  part  operated  upon,  in 
order  to  avoid  its  penetrating  more  deeply  on  one  side  than  the  other, 
and  thus  suddenly  and  unawares  wound  the  cerebral  membranes.  It 
is  important  to  examine  the  depth  of  the  groove  frequently  with  a 
probe,  to  ascertain  how  nearly  the  instrument  has  completed  the 
section  of  the  bone;  the  teeth  of  the  trephine  may  occasionally  re- 
quire cleaning  with  a  small  brush  or  wet  sponge.  The  disc  of  bone 
should  be  raised  with  the  point  of  the  elevator  e,  and  the  edges 
smoothed  with  the  lenticular  knife  at  its  other  end. 

IV.  OSTEOPLASTY. 

The  transplantation  of  bone  consists  in  raising  bone,  covered  with 
its  periosteum,  and  placing  it  in  a  new  position  for  the  ])urpose  of 
filling  gaps  created  by  disease  or  operations.  The  superior  maxilla 
has  been  resected  so  far  as  to  permit  the  removal  of  naso-pharyngeal 
polypi,  and  been  replaced  with  perfect  restoration  of  its  integrity;^ 
portions  of  the  hard  palate  have  been  cut  away  and  placed  in  appo- 
sition with  similar  sections  from  the  opposite  in  staphyloraphy ;  ^ 
the  chasm  between  the  fragments  of  ununited  bone  has  been  success- 
fully filled  by  dividing  the  long  axis,  and  turning  it  down  so  that  it 
filled  the  space.  The  requisite  to  success  is  the  preservation  of  the 
fibrous  and  periosteal  attachments  of  the  fragment  removed  to  the 
bone  from  which  it  is  separated. 

1  Von  Langenbeck.  2  gir  "w_  Fergusson. 


INJURIES   OF  JOINTS.  147 

CHAPTER   XV. 

INJURIES  OF  JOINTS   AND   SPECIAL   OPERATIONS. 

Joints  are  composed  of  the  two  ends  of  bones  covered  with  car- 
tihige;  of  a  sac  frequently  contahiing  many  appendages,  pockets,  and 
bulgings;  of  a  synovial  membrane,  a  fibrous  capsule,  and  the  strength- 
ening hganients.i  It  is  owing  to  the  intimate  relations  of  these  com- 
plicated structures  that  the  injuries  and  diseases  of  joints  are  pe- 
culiarly serious. 

I.    WOUNDS. 

On  account  of  their  exposed  positions  joints  are  specially  liable 
to  wounds  of  various  forms  and  degrees  of  severity. 

1.  Contused  •wounds  may  be  so  severe  as  to  be  followed  bv  ex- 
travasation of  blood  into  the  tissue  around  it,  or  even  into  its  cavity. 
Examine  first  for  a  fracture,  then  apply  apparatus  to  secure  perfect 
rest,  and  the  ice-bag  to  prevent  inflammation;  the  gypsum  dressing 
with  a  suitable  fenestrum  at  the  joint  is  the  best  apparatus  for  the 
injury  of  joints  of  the  lower  extremity. 

2.  A  punctured  wound  is  dangerous,  owing  to  the  tendency  to 
suppurative  inllammatiou  and  the  retention  of  the  pus.  That  the 
joint  is  involved  is  known  by  the  escai)e  of  synovia.  Pursue  the  fol- 
lowing treatment  :  Place  the  patient  in  be<l,  close  the  wound  with 
collodion  or  adhesive  plaster,  if  it  is  slight,  but  with  sutures  accu- 
rately applied  if  it  gape;  secure  perfect  rest  to  the  joint  by  immov- 
able apparatus,  and  if  any  application  is  made,  use  cold.  In  favor- 
able cases  all  excitement  about  the  joint  will  subside  in  a  few  days, 
and  when  the  dressings  are  removed  at  the  end  of  four  to  six  weeks, 
recovery  will  be  complete.^ 

3.  An  incised  wound  is  also  recognized  as  having  penetrated 
the  joint  by  the  appearance  of  synovia.  Such  a  wound  must  be 
treated  and  dressed  antiseptically;  close  it  accurately  with  sutures, 
apply  immovable  apparatus  to  the  limb,  and  locally  use  ice-bags; 
give  cooling  regimen.  If  the  case  proceed  favorably,  retain  anti- 
septic dressings  until  luiion  is  firm,  then  commence  passive  motion, 
but  restrict  it  for  at  least  one  month. 

4.  A  lacerated  wound  should  be  treated  as  follows:  Cleanse  the 
wound  of  all  foreign  matters  under  the  spray,  pare  the  edges  of  all 
contused  tissues,  and  if  possible  close  the  wound  with  silver  wire 
sutures  and  treat  it  as  an  incised  wound;  if  large,  gaping,  and  cannot 
be  closed  under  the  carbolic  spray,  enlarge  the  opening  wherever  it 

1  T.  Billroth. 


148  OPERATIVE  SURGERY. 

is  necessary  to  gain  free  drainage  of  the  cavity  of  the  joint,  inject 
carbolic  solutions,  1  to  20,  to  destroy  septic  ferments  which  may  have 
entereil  the  joint;  introduce  the  drainage  tube  or  a  horse-hair  drain, 
carbolized;  apply  antiseptic  dressings  and  immobilize  the  joint  by 
apparatus  ;  renew  the  dressings  within  twelve  hours,  and  repeat  them 
as  often  as  necessary  to  prevent  accumulation  of  secretions  in  the 
wound. ^  However  favorably  the  case  proceeds,  the  joint  must  be 
retained  in  a  state  of  perfect  rest  for  at  least  two  weeks,  when  pas- 
sive motion  may  be  begun,  but  if  it  produce  any  swelling  of  the 
joint  or  tenderness,  all  motion  must  cease  for  several  days,  when  it 
may  be  renewed. 

II.    DISLOCATIONS. 

A  joint  is  dislocated  when  one  bone  is  displaced  fi'om  another  at 
its  place  of  natural  articulation;  there  may  be  no  other  injury  than 
rupture  of  the  capsule,  simple  dislocation,  or  there  may  be  a  wound 
of  the  integument  entering  the  joint,  compound  dislocation.  The 
signs  of  dislocation  are,  preternatural  immobility,  and  tendency, 
when  reduced,  to  remain  ;  but  with  free  motion  without  crepitus. 
The  treatment  required  is  immediate  reduction;  anjesthetics  must  be 
used  for  relaxation;  when  reduction  is  possible  by  manipulation  this 
method  should  always  be  pi'eferred;  if  more  force  is  necessary,  make 
extension  and  counter-extension  with  the  hands, 
aided  with  bandages  tied  in  the  form  of  the  clove- 
hitch  (Fig.  121);  if  more  power  is  required,  re- 
sort to  mechanical  contrivances,  as  the  pulley. 
Compound  dislocations  are  among  the  most  seri- 
ous accidents  which  can  befall  a  limb ;  ^  but  it 
must  be  borne  in  mind  that  by  the  proper  use 
of  antiseptic  dressings  these  injuries  may  now 
be  treated  without  suppuration,  and  are  therefore 
Fig.  121.  £,^j.  uiore  amenable  to  conservative  measures  than 

formerly.  The  treatment  must  depend  upon  the  amount  of  injury 
in  each  case;  if  slight,  reduction  maybe  effected  by  suitable  en- 
largement of  the  wound,  followed  by  thorough  cleansing  and  dis- 
infection ;  resection  should  be  made  when  the  bones  are  destroyed,  the 
antiseptic  dressings  being  employed;  amputation  will  be  necessary 
when  the  principal  artery  of  the  limb  is  ruptured,  or  there  is  destruc- 
tion of  the  tissues  about  the  joint,  or  the  patient  is  old  or  feeble. 

1.  The  temporo-niaxillary  joints  are  dislocated  by  the  dis])lace- 
ment  of  the  condyles  of  the  lower  jaw  forwards,  one  or  both,  the  lat- 
ter being  more  frequent.  Reduce  as  follows:  The  patient  seated  on 
the  floor  with  the  head  between  the  knees  of  the  operator,  place  a 

1  J.  Lister.  2  x.  Bryant. 


INJURIES  OF  JOINTS.  149 

couple  of  pieces  of  cork,  gutta  percha,  or  pine  wood  as  far  back  be- 
tween the  molars  as  possible;  now  draw  the  chin  steadily  upwards, 
taking  care  not  to  draw  it  forward  at  the  same  time;  or,  sitting  or 
standing  in  front  depress  the  comlyles  by  means  of  the  thumiis  pro- 
tected by  pieces  of  leather  jilaced  on  the  tops  of  the  molars ;  if  this 
method  fail,  reduce  one  side  at  a  time,  or  give  an  ansesthetic;  after 
reduction  sii])|)()rt  the  jaw  with  a  bandage. 

2.  The  vertebral  articulations  are  rarely  <lis])laced  without  frac- 
ture, especially  in  the  lumbar  and  dorsal  regions.  In  the  eervieal 
region  forward  and  backward  luxations  may  oecur  with  or  without 
fracture.  Reduction  should  always  be  attempted.  If  the  lumbar  or 
dorsal  vertebra;  are  displaced  make  forcible  e.\ten«;ion  with  judicious 
lateral  motion  and  direct  pressure  upon  the  spine.  Jf  a  cervical  ver- 
tebra is  tlis|>laeed  raise  the  head  firmly  by  the  chin  and  occiput,  and 
if  reduction  does  not  follow,  add  slight  rotation  in  the  direction  of 
dislocation  to  disengage  the  process,  or  place  the  patient  on  the  back 
and  make  extension  in  the  same  manner. 

3.  The  sterno-clavicular  joint  may  be  dislocated  by  the  displace- 
ment of  the  end  of  the  clavicle  forward,  upwards,  or  backwards. 
Reduction  is  eft'ected  by  elevating  the  shoulder  in  pushing  upward 
at  the  elbow,  or  by  drawing  the  shoulders  backward  and  upward 
with  the  knee  pressing  aixainst  the  spine  between  the  scapula. 
Though  frequently  it  is  difficult  to  retain  the  davitle  in  position,  the 
function  of  the  arm  is  ranly  impaired.  For  the  first  and  second 
forms,  the  pad  in  the  axilla,  the  sling  for  the  elbow,  and  a  pad  upon 
the  displaced  bone,  retained  by  adhesive  straps,  are  most  useful ;  for 
the  third  form,  rest  on  the  back,  or  such  appliance  as  will  retain  the 
shoulder  upwards  and  outwards,  are  required. 

4.  The  acromico-clavicular  joint  may  be  luxated  by  the  upward 
or  downward  displacement  of  the  end  of  the  clavicle  :  reduction  is  ef- 
fected by  drawing  the  shoulder  outward  and  backward.  The  retain- 
ing apparatus  for  the  upward  luxation  should  be  applied  as  follows:^ 
Place  a  compress  over  the  articulation,  and  retain  it  by  two  strips  of 
adhesive  plaster,  the  ed'.'es  being  glued  to  the  skin  by  collodion  ; 
bandage  the  hand  and  forearm  with  a  flannel  roller ;  npplv  a  loop 
of  elastic  bandage'^  five  feet  long  and  one  inch  and  a  half  wide, 
passe<l  under  the  elbow  of  the  injured  side;  draw  the  ends  snu<rlv 
over  the  compress,  carrying  the  anterior  one  around  the  a.xilla  of  the 
sound  side,  as  in  a  spica  of  the  shoulder,  to  join  the  other  between 
the  clavicles,  where  they  are  fastened  with  strong  pins.  Complete 
and  iH-rmanent  nstoration  rarely  follows  any  treatment.^ 

5.  The  shoulder  joint  dislocations  consist  of  the  displacement  of 
the  head  of  the  humerus  ;  first,  downwards  into  the  axilla;  second, 

1  \V.  T.  Bull.  -  H.  A.  Martin.  3  V.  II.  HamUton. 


150 


OPERATIVE  SURGERY. 


forward  under  the  coracoid  process;  and  third,  backwards  under  the 
spine  of  the  scapula.  The  reliable  sign  of  these  displacements  is  the 
projection  of  the  elbow  from  the  chest  when  the  hand  of  the  dislo- 
cated arm  is  placed  upon  the  opposite  shoulder.  The  method  of  reduc- 
tion in  the  first  two  varieties  is  the  same;  proceed  as  follows:  Flex 
the  forearm  upon  the  arm,  and  while  the  arm  is  elevated  to  a  right 
angle  with  the  trunk,  rotate  gently  forwards  by  depressing  the  hand 
and  forearm;  or  place  the  knee  in  the  axilla  to  press  the  head  outward 
and  serve  as  a  fulcrum,  and  use  the  shaft  as  a  lever;  or  laying  the 
patient  down,  place  the  heel  against  a  pad  in  the  axilla,  and  grasp- 
ing the  wrist  and  elbow,  make  steady  traction,  meanwhile  prying  the 
head  outward  with  the  heel ;  failing,  give  an  anajsthetic.^  Reduction 
may  also  be  effected  by  manipulation:  grasp  the  shoulder  with  one 
hand  and  the  flexed  elbow  with  the  other,  make 
extension  at  the  elbow,  drawing  it  from  the  side 
(Fig.  122)  with  slight  rotatory  motion  outwards; 
when  extension  is  fully  made,  raise  the  elbow 
and  with  the  arm  describe  a  semicircle  towai'us 
the  sternum  and  face,  then  suddenly  depress  the 
elbow  upon  the  thorax,  rotating  the  head  of  the 
humerus  inwards  and  with  the  thumb  of  the 
right  hand  giving  the  proper  direction  to  the 
head  (Fig.  123);  this  manoeuvre  may  be  re- 
peated if  necessary. 2  In  the  subspinous  form 
make  extension  towards  the  joint,  or  resort  to  the  last  method,  stand- 
ing behind  the  patient  and  drawing  the  elbow  back- 
ward and  rotating  the  bone  while  the  thumb  of  the 
''l  right  hand  guides  the  head  to  the  joint.  In  com- 
pound dislocation  the  question  as  to  the  propriety  of 
reduction  or  resection  should  be  decided  as  follows: 
In  a  healthy  patient,  without  complications,  reduction 
'is  preferable;  but  if  the  patient  is  weak  or  old,  or 
the  exposed  bone  is  badly  injured,  or  the  parts  are 
much  lacerated,  saw  off  the  exposed  head  of  the  bone.* 
Antiseptic  dressings  should  be  scrupulously  applied. 
Fig.  123.2  ^    ^j^^  elbow  joint  may  be  di^located  by  displace- 

ment of  the  ulna  and  radius  backwards,  forwards,  inwards,  outwards, 
the  last  two  being  partial.  Examine  carefully  to  determine  whether 
there  is  a  transverse  fracture  of  the  humerus,  or  of  one  condyle,  or 
of  the  olecranon.  Reduce  the  first  form  thus  :  the  patient  seated 
in  a  chair,  press  the  knee  in  the  bend  of  the  elbow  and  flex  the  arm 
forcibly  but  slowly  around  it.^    Other  methods  are  as  follows:  the  pa- 

1  F.  H.  Hamilion.  2  t.  Bryant.  3  H.  11.  Smith.  4  T.  Holmes. 

0  Sir  A.  Cooper,  F.  H.  Hamilton. 


Fig.  122.2 


INJURIES   OF  JOINTS.  1'>1 

tii'nt  being  soatcd,  carry  the  arm  ami  forearm  dirt'Ctly  backwards, 
the  scapula  being  ])resse(l  forwards  ;i  extension  of  tlie  forearm  from 
the  hand  or  wrist  (h>wnwards  ; '^  extension  of  the  forearm  from  its 
middle  bv  an  assistant,  while  the  surgeon  seizes  upon  the  olecranon 
process  with  the  fingers  of  one  hand  and  placing  the  palm  of  the  otlier 
against  the  front  and  upper  part  of  the  forearm  pulls  forcibly  back- 
wanls.8  The  second  form  may  be  reduced  by  forced  flexion  aided  by 
pressure;  the  lateral  displacements  are  restored  by  moderate  extension 
combined  with  lateral  pressure.*  The  head  of  the  radius  may  be  dis- 
placed separately  forwards,  outwards,  and  backwards,  the  first  being 
far  the  most  frecpient ;  reduction  is  effected  in  all  forms  by  extension 
aided  by  pressure  upon  the  head  of  the  radius  made  in  the  right  direc- 
tion.'* In  compound  dislocations  in  healthy  jjatients,  reduce  the  bones 
and  close  the  wound  antiseptically,  unless  there  is  much  comminu- 
tion, when  excision  of  the  bones  involved  should  be  performed;  in 
general,  a  useful  limb  results  from  these  excisions  of  the  joint  surfaces. 

7.  The  wrist  joint  is  luxated  by  displacement  of  the  carpus  for- 
wards or  backwards;  reduction  is  made  by  extension  in  a  straight 
line  with  slii;lit  rocking  or  lateral  motions  if  necessary.* 

8.  The  phalangeal  joints  may  be  dislocated  and  are  generally 
easily  reduced.  The  dis])lacement  of  the  first  phalanx  of  the  thumb 
upon  its  metacarpal  bone  is  an  exception;  the  difficulty  of  reduction 
is  due  to  the  escape  of  the  head  of  the  metacarpal  bone  between  the 
two  tendons  of  the  flexor  brevis,  where  it  is  lodged  as  in  a  button- 
hole.^ Reduction  is  effected  by  first  pressing  the  metacarpal  bone 
firmly  to  the  centre  of  the  palm  to  relax  the  short  flexor,  then  put- 
ting the  displaced  phalanx  in  a  state  of  extreme  extension  to  relax 
the  tissues  of  the  button-hole  and  to  push  up  those  which  form  its 
distal  part  over  the  projecting  head  of  the  metacarpal  bone;  this  is 
done  by  dragging  the  hyper-extended  thumb  downwards  or  away 
from  the  wrist,  and  then  acute  flexion  will  restore  it  to  its  place.* 
If  this  method  fail,  with  a  very  narrow  bladed  tenotome  divide  the 
insertions  of  the  flexor  tendon  and  repeat  the  manoeuvre. 

9.  The  hip  joint  ^  is  protected  and  strengthened  by  the  ilio-fem- 
oral,  or  inverted  Y  ligament,  which  is  inserted  al)ove  into  the  front 
and  outside  of  the  inferior  spinous  process  of  the  ilium,  and  below  into 
the  anterior  inter-trochanteric  line  ;  it  has  two  main  branches,  extend- 
ing, the  outer  to  the  trochanter  major,  and  the  inner  to  the  trochan- 
ter minor;  in  regular  dislocations  this  ligament  is  unbroken  and 
controls  largely  the  movements  of  the  head  of  the  fenun-.  The 
several  positions  of  the  lu-ad  of  the  bone  with  reference  to  the  socket 
may  be  reduced  to  the  following,  namely,  (1.)  The  dorsal,  including 

1  R.  Listen,  J.  Miller.      2  F.  C.  Skey.       »  J.  Pirre.        ••  F.  H.  Hamilton. 
6  Fal)l)ri.  *»  T.  Holmes.         '  H.  J.  Bigelow. 


152  OPERATIVE  SURGERY. 

tliat  on  the  tuberosity,  the  dorsal,  the  everted  dorsal,  the  anterior 
oblique,  and  the  supra-sjnnoiis.  (2.)  The  thj-roid,  including  that  on 
the  perineum  and  on  the  thyroid  foramen.  (3.)  The  pubic,  the  pubic 
and  sub-sj)iiious.  Though  the  head  of  the  bone  may  be  jjriniaril}' 
luxated  in  various  directions,  yet  the  downward  dislocation  is  by  far 
the  most  common,  as  the  capsule  is  thin  and  weak  at  this  part,  and 
flexion,  by  which  the  ligament  is  relaxed,  with  adduction  or  abduc- 
tion, is  the  habitual  attitude  of  the  thigh  in  action  and  self-defense. 
From  this  jjosition  the  head  of  the  bone  readily  passes  to  the  dorsal, 
or  thyroid,  or  pubic  regions;  thus  all  regular  dislocations  may  be  sec- 
ondary. These  several  positions  are  sufficiently  well  recognized  for 
reduction  by  the  following  sign,  namely:  the  head  of  the  femur  al- 
ways faces  the  same  way  as  the  internal  condyle.  As  a  preliminary 
to  reduction,  etherize  the  patient  to  relaxation,  and  place  him  re- 
cumbent on  the  floor.  The  best  general  rule  for  reducing  a  recent 
dislocation  is  to  get  the  head  of  the  femur  directly  below  the  socket 
by  flexing  the  thigh  at  about  a  right  angle,  and  then  to  lift  or  jerk  it 
forcibly  up  into  its  place.  This  rule  applies  to  all  dislocations  except 
the  ])ubic,  and  even  to  that  when  secondary  from  below  the  socket ; 
the  reduction  by  the  lifting  method  is  usually  instantaneous,  and 
flexion  is  the  basis  of  its  success  (Fig.  124).  If  after  one  or  two 
trials  it  appears  that  the  bone  cannot  be 
jerked  into  place,  enlarge  the  rent  in  the 
capsule  a  little  by  moving  the  flexed  thigh 
from  one  side  to  the  other  so  as  to  sweep 
^the  head  of  the  femur  across  below  the 
socket;  and  again  repeat  the  act  of  lifting. 
The  following  rules  for  reduction  of  the 
Fig.  124.  femur  from  its  several  ])ositions,  should  be 

observed  :  (1-)  In  dorsal  dislocations,  flex  and  forcibly  lift;  if  this 
effort  fnil,  flex  and  lift  while  abducting.  If  this  fail  it  will  be  found 
that  abduction  has  carried  the  head  of  tlie  bone  from  the  dorsum 
nearly  or  quite  to  the  thyroid  foramen,  and  that  the  capsular  rent  has 
been  so  enlarged  that  the  first  method  may  now  prove  successful. 
(2.)  In  thyroid  dislocations,  adduction  of  the  flexed  thigh  reverses 
this  movement  and  carries  the  head  from  the  thyroid  foramen  to  the 
dorsum,  ami  also  enlarges  the  opening,  making  the  first  rule  effective. 
(3.)  The  pubic  dislocations  may  generally  be  brought  down  without 
difficulty  from  above  the  socket,  after  flexion,  especially  if  they  are 
secondary,  and  may  then  be  reduced  from  that  i)osition  like  the  thy- 
roid. 

A  fulcrum  marie  by  rolling  one  or  more  sheets  into  a  firm  band,  two  or  three 
inches  in  diameter,  maj'  aid  the  manipulator.  Plkce  the  centre  of  the  band  in 
the  groin,  and  while  assistants  raise  the  ends  by  pressure  at  tiie  knees,  the  head 


INJURIES   OF  JOINTS.  153 

is  lifted  into  the  socket. l  Tlie  same  result  is  secured  by  requiriiifj;  an  assistant 
to  lift  the  head  of  the  bone  by  means  of  a  stout  sheet  in  the  t(roin  and  o%-er  his 
shoulders. 

10.  The  patella  may  bo  displaced  outwards,  inwards,  or  on  its 
own  axis  ;  rrdiiction  is  made  by  layiiijjj  the  patient  on  tlie  floor,  lifting 
the  limb  with  the  heel  upon  the  shoulder  so  as  to  rela.\  completely 
the  (piadriceps  muscle,  ami  pushing  the  patella  into  position  ;  if  this 
eiTort  fails  in  the  last  form  ile.\  the  thi;^h  and  straighten  the  leg  while 
pressure  is  made  on  the  patella.^ 

11.  The  knee  joint  is  dislocated  by  displacement  of  the  til)ia 
backwards,  forwards,  outwards,  and  inwards,  but  in  general  the  lux- 
ation is  incomplete.  Reduction  is  generally  effected  without  nuich 
difficulty.  If  backward,  use  forced  and  extreme  flexion  ;  if  forward, 
reverse  the  movement ;  if  lateral,  make  extension  an<l  j)ressure. 

12.  The  ankle  joint  is  luxated  by  the  displacement  of  the  tiijia 
forwards  and  l)a(k wards.  Reduction  is  cflfected  by  extension  and 
counter-extension  combined  with  pressure.  Division  of  the  tendo- 
Achillis  has  been  found  necessary  in  eases  of  backward  luxation. 
Dislocation  outwards  or  inwards  is  a  rotation  of  the  astragalus,  accom- 
panied usually  with  a  fracture  of  the  (ibida  and  rupture  of  the  inter- 
nal lateral  ligament.^  Compound  dislocations  are  not  infrequent  at 
the  ankle-joint,  and  always  demand  the  most  judicious  care;  as  in 
other  compound  dislocations  the  conditions  present  must  determine 
the  course  of  procedure.  By  conservative  measures  in  young  and 
healthy  persons,  where  the  vessels  have  escaped  damage,  and  there  are 
no  other  serious  complications,  the  limb  and  joint  may  often  be  saved. 
The  wound  should  be  cleansed  of  all  foreign  matters,  carbolic  solutions, 
1  to  20,  should  be  injected  into  all  its  recesses,  and  antiseptic  jute 
or  cotton,  soaked  in  carbolized  oil,  applied  to  the  opening;  the  joint 
must  be  iinmol)ilized  by  the  fenestrated  gypsum  bandage,  unless  there 
is  great  swelling,  when  the  splint  must  be  used.  Anchylosis  will  en- 
sue, but  the  increased  mobility  of  the  transverse  tarsal  joint  will  in  a 
great  measure  compensate  for  this  loss.^  When  there  is  much  com- 
minution removal  of  the  fragments  is  necessary,  or  excision  of  the  joint 
may  be  reciuired,  followed  by  the  dressings  already  given.  In  a  cer- 
tain proportion  of  cases,  the  injury,  or  health,  or  age  of  the  patient, 
renders  amputation  the  oidy  safe  course. 

13.  The  tarsal  bones  may  l)e  luxated  from  their  positions,  but 
generally  the  great  violence  which  causes  such  displacement  does 
severe  injury  to  the  tarsus.  Luxations  of  the  astragalus  are  far  the 
most  important;  the  dislocations  of  this  bone  may  be  forwards,  back- 
wanls,  oatwanls,  and  inwards,  or  it  may  be  rotated  on  its  axis.  As 
a  rule,  if  the  dislocation  is  simj)le,  attempt  immediate  reduction;  if 

1  G.  Sutton.  2  F.  H.  I1a.milton.  3  T.  Holmes. 


154  OPERATIVE  SURGERY. 

the  luxation  is  complete  and  reduction  impossi'ule,  resect;  if  the  lux- 
ation is  compound,  resect;  if  there  is  severe  laceration,  or  other  in- 
juries complicating  these  conditions,  amputate.  Reduction  is  effected 
by  extension  from  the  foot,  grusped  as  in  removing  a  boot,  and  counter- 
extension  from  the  knee,  with  such  pressure  upon  the  displaced  bone 
as  may  be  required.  If  ihe  astragalus  is  displaced  from  the  scaphoid 
and  calcaneus  the  treatment  is  the  same. 


CHAPTER  XVI. 

DISEASES   OF   THE   JOINTS   AND   SPECIAL   OPERATIONS. 

It  may  be  stated  as  a  general  truth  that  diseases  of  a  joint  com- 
ntence  either  in  the  synovial  or  osseous  tissues,  and  that  they  origi- 
nate for  the  most  part  in  an  acute  or  chronic  inflammation;  in  the 
progress  of  any  case  both  tissues  may  become  eventually  involved; 
practically  there  is  no  primary  disease  of  articular  cartilages,  and 
when  they  undergo  a  change  it  is  secondary  to  some  other  affection, 
either  of  the  synovial  membrane  or  of  the  bone;  when  the  disease 
commences  in  the  synovial  membrane  or  in  ihe  bone,  and  disorganiza- 
tion of  the  joint  follows,  it  is  in  that  tissue  in  which  the  disease  began 
that  the  gravest  change  will  be  seen.^ 

I.    INFLAMMATION. 
Injury  in  some  form  is  generally  the  cause  of  inflammation  of  the 
joints.      The  various  wounds   already  mentioned   are   liable  to  ter- 
minate in  inflammation,  announced  by  swelling  and  heat  of  the  part, 
pain  on  pressure,  and  fever. 

1.  Serous  synovitis-  commences  with  swelling,  heat,  and  pain 
of  the  joint,  but  slight  fever;  the  synovial  membrane  is  slightly 
swollen  and  moderately  vascular;  the  cavity  is  full  of  serum  with  sy- 
novia, and  the  remainder  of  the  joint  is  healthy.  The  symptoms 
rapidly  subside  with  rest,  painting  with  the  tincture  of  iodine,  or 
applying  compresses  of  wet  bandages,  or  blisters;  the  patient  soon 
begins  to  use  the  joint  without  difliculty,  the  fluid  is  gradually  ab- 
sorbed and  function  is  restored. 

2.  Parenchymatous  or  purulent  synovitis  -  begins  with  a  chill, 
high  fever,  extreme  tenderness  of  the  joint  which  is  fixed,  swollen, 
and  hot;  there  is  no  fluctuation,  but  the  whole  limb  is  oedematous; 
the  synovial  membrane  much  swollen,  red,  and  puffy;  there  is  a  lit- 
tle flocculent  pus  in  the  cavity,  and  the  cartilage  looks  cloudy ;  the 
difference  between  the  serous  and  purulent  varieties  is  that  in  the 

i-T.  Brvant.  2  t.  Billroth. 


DISEASES   OF   THE  JOISTS.  '        155 

former  the  synovial  membrane  is  simply  stimulated  to  secretion, 
while  in  the  latter  it  is  deeply  affected.  The  treatment  at  this  early 
stage  is  :  (1)  fixation  of  the  joint  by  appai-atus,  in  the  most  favorable 
position  for  subsequent  use  if  anchylosis  occur,  anaesthetics  being 
given  if  necessary  ;  the  gypsum  is  generally  the  most  available,  the 
limb  being  well  protected  by  wadding  to  avoid  stran:^ulation;  (2) 
the  continued  ap[)lication  of  ice-bladders  so  as  to  effectually  cool  the 
entire  joint.  Before  ap[>lying  these  dressings  the  parts  may  be  thor- 
ou'dily  painted  with  tr.  iodine.  Opium  and  quinine  should  be  given 
in  such  measure  as  will  secure  relief  from  the  effects  of  pain  and 
fever.  If  the  disease  subsides  months  may  elapse  before  the  inflam- 
mation entirely  disap[)ears,  and  great  care  is  necessary  to  avoid  a 
renewal  of  the  disease  by  cold  or  injury.  If  the  disease  continues  to 
progress  abscesses  form,  the  joint  becomes  more  swollen,  the  fever 
is  high,  and  inter-current  chills  occur,  emaciation  follows,  with  sleep- 
lessness and  prostration;  in  the  joint  there  is  a  collection  of  thick 
yellow  pus  mixed  with  fibrinous  flocculi,  the  synovial  membrane  is 
covered  with  dense  purulent  rinds  under  which  it  is  very  red  and 
puffy,  partly  ulcerated;  the  cartilage  is  partly  broken  down  into 
pulp,  partly  necrosed  and  peels  off,  the  bone  is  very  red  or  infiltrated. 
The  limb  being  secureil  in  immovable  apparatus,  with  ami)lefenestr8e, 
open  the  absces.-^es  and  the  joint  anti>epticaily,  thorouuhly  cleanse 
with  carbolic  solutions,  secure  free  drainage,  and  give  opium,  qui- 
nine, and  nourishing  diet  liberally.  The  patient  may  recover  under 
this  treatment  with  anchylosis,  or  metastatic  abscess  may  form  in 
the  lungs,  liver,  or  other  organs,  and  death  ensue  from  pyjemia. 
Occasionally  the  inflammation  extends  uncontrollably  in  and  around 
the  joint,  the  suppuration  involving  the  thigh  and  leg,  followed 
by  great  exhaustion,  fever,  and  chills.  Recovery  is  still  possible, 
but  openings  must  be  made  to  evacuate  the  pus,  and  strengthen- 
ing remedies  given.^  The  antiseptic  treatment  is  most  service- 
able in  such  cases;  every  collection  of  pus  must  be  evacuated;  all 
septic  matters  removed  and  cavities  cleansed  with  carbolic  solutions, 
and  antiseptic  dressings  applied.^  The  question  of  exsection  or 
amputation  may  arise  in  severe  cases  and  must  be  determined  by  the 
special  conditions  of  each  case. 

3.  Chronic  synovitis  may  result  from  the  acute  form,  or  it  may 
be  chronic  from  the  start  and  remain  so.  The  joint  is  much  swollen, 
without  heat  or  pain,  and  fluctuates  all  over;  the  fluid  collects  chiefly 
in  tlie  mucous  bursas  adjacent,  especially  at  the  knee,  where  the  bursae 
under  the  tendons  of  the  extensors  at  both  sides  of  the  patella  and 
in  the  popliteal  space  are  greatly  distended,  while  the  capsule  is  less 
distinctly  marked  than  in  acute  synovitis;  the  patient  can  often  walk 
1  T.  Billrotfi.  2  J.  Lister. 


156       '  OPERATIVE  SURGERY. 

easily,  but  nuidi  exercise  is  fatiguing  and  followed  by  increased  effu- 
sion.^ The  cure  requires  rest  to  the  joint,  and  change  in  the  syno- 
vial surfaces.  Rest  may  generally  be  best  secured  by  plastic  dress- 
ing, both  in  the  upper  and  lower  extremity.  To  effect  a  change  in 
the  synovial  membrane  apply  blisters  or  iodine;  if  it  still  remains 
filled  with  fluid,  it  may  be  tapped  with  a  fine  trocar,  and  the  fluid 
withdrawn  ;  or,  if  the  fluid  return,  to  tapping  add  an  injection  of  io- 
dine. The  arrest  of  secretion  in  the  latter  case  is  due  to  the  shrink- 
age of  the  serous  membrane  caused  by  the  action  of  the  iodine,  with 
the  new  formation  of  endothelium.^  Tap  the  joint  carefully  with 
a  fine  trocar,  and  after  the  escape  of  the  fluid,  without  admitting 
air,  inject  by  means  of  a  well-made  syringe  officinal  tincture  of 
iodine  and  distilled  water,  ecjual  parts,  or,  if  it  is  desired  to  be  more 
cautious,  take  one  of  the  former  to  two  of  the  latter;  be  careful  that 
no  air  enter  the  joint;  allow  the  litjuid  to  remain  from  three  to  five 
minutes,  according  to  the  pain  induced,  then  let  it  escape  slowly, 
close  the  wound,  and  envelop  tlie  joint  with  wet  bandages;  the  opera- 
tion is  not  free  from  danger  and  may  terminate  in  purulent  syno- 
vitis.^ 

II.    CARIES. 

Two  forms  of  destructive  ulceration  occur  in  the  articular  extrem- 
ities of  bones,  which'are  liable  to  seriously  compromise  joints. 

1.  Simple  caries  ^  attacks  tlie  articular  ends  of  bones  as  a  sequel 
of  inflammation  of  other  tissues  of  the  joint;  it  sets  in  as  soon  as  the 
cartilafi^e  which  coats  tlie  articular  surfaces  is  finally  destroyed,  and 
the  bare  bone  is  left  projecting  into  the  cavity  of  the  joint;  by  me- 
chanical violence  minute  portions  of  bone  tissue  are  successively  de- 
tached with  the  debris  which  surrounds  them;  the  ulcer  is  invariably 
superficial,  sharply  circumscribed,  and  relatively  smooth;  it  is  com- 
monly situated  where  the  opposed  surfaces  are  in  contact  with  each 
other;  though  slow  in  its  progress  it  causes  extensive  losses  of  sub- 
stance followed  by  marked  shortening  and  distortion  of  the  limb. 
The  first  symptoms  may  be  slight  heat,  pain,  and  swelling,  followed 
in  a  few  weeks  by  gnawing  pains  and  starting  of  the  limb  at  night 
from  spasms  of  the  muscles,  great  pain  on  rubbing  the  joint  surfaces 
together,  contraction  of  the  limb;  finally  pus  forms  and  abscesses  ap- 
pear with  their  attendant  symptoms.^  The  indications  of  treatment 
are,  (1)  tonics,  as  syr.  ferri  iodid,  and  cod  liver  oil;  (2)  complete 
relief  of  the  carious  bone  from  pressure  and  friction  by  extension,  with 
apparatus  adapted  to  the  special  joint  involved.  If  the  caries  extends, 
exsection  or  amputation  may  be  required. 

2.  Fungating  caries,  fungous  or  scrofulous  inflammation  of  a  joint 

1  T.  Billroth.  2  £.  Rinddeiscli. 


DISEASES   OF   THE  JOL\TS.  157 

may  orit;inate  in  the  synovial  nii'inhrane,  or  lh«TL'  may  be  a  cen- 
tral or  more  rarely  a  peripheral  caries  in  the  spon'jry  epiphysis  of  a 
hollow  bone  or  in  one  of  the  sponjiy  bones  of  the  wrist  or  ankle  which 
niav  perforate  from  within  outward  and  excite  synovitis;  sometimes 
in  the  hip,  knee,  and  ankle  with  the  fungous  ])roliferation  of  the 
synovial  membrane,  there  is  an  independent  proliferation  under  the 
cartilage  and  between  it  and  the  bone,  wliich  subsequently  unites 
Avith  that  above,  so  that  the  cartilage  lies  partly  movable  between 
the  two  granular  layers. ^  More  commonly  the  disease  connnences 
as  a  non-suppurative  inflammation  of  the  adjoining  epipliyses  of  two 
bones  where  they  unite  to  form  a  joint;  the  hypera'mie  medulla 
grows  towards  the  joint,  the  bony  trabecula?  melt  away,  the  cortical 
portion  becomes  thin,  the  exuberant  granulations  protrude  between 
the  cartilage  and  bone;  meantime,  the  synovial  membrane  and 
its  connective  tissue,  the  ligaments,  and  finally,  all  of  the  neighbor- 
ing connective  tissue  inflames;  a  diffuse  congestion  occurs  in  the  deli- 
cate, overlapping  fringe  of  the  synovial  membrane,  from  which  a 
membrane  of  young  connective  tissue  overspreads  the  cartilage  from 
its  edges;  the  superficial  layer  of  cartilage  cells  now  take  part  in  the 
inflanmiation,  cells  multiply,  the  capsules  open,  the  young  connective 
tissue  forces  its  way  in  ;  finally,  the  ascending  growth  meets  that 
which  is  advancing  downwards,  the  two  coalesce,  and  the  cartilage 
is  perforate<1.2  The  disease  may  terminate  in  resolution,  and  the 
parts  recover,  or  pus  may  form  in  the  joint  or  in  the  tissues  around 
it,  creating  abscesses  with  sinuses;  or  the  connective  tissue  may  en- 
lai'ge  and  degenerate  into  a  firm,  white,  fibroid  mass  of  colossal  di- 
mensions, stretching  the  skin  allaroun<l  the  joint  and  shining  through 
it  with  a  whitish  lustre,  causing  the  so-called  white  swelling,  tumor 
albus.2  The  external  appearances  of  the  affected  joint  depend 
upon  the  extent  of  participation  of  the  parts  around  the  joint  in  the 
inflammation  ;  there  may  be  no  suppuration  but  a  simple  prolifera- 
tion of  granulations  which  shall  lead  to  destruction  of  ligaments  and 
displacement  of  bones;  or  suppuration  may  occur  in  the  granulations 
or  synovial  meml)rane,  or  in  the  connective  tissue;  whatever  swelling 
there  may  be  around  the  joint  is  due,  not  to  enlargement  of  the  artic- 
ular ends  of  bones  which  never  swell  in  curies,  but  to  the  thickening 
of  the  soft  parts  or  to  osteophytes.^  The  disease  is  frequent  in 
childhood. 

When  f ungating  caries  attacks  spongy  bones,  which  are  largely  in- 
vested by  articulations,  as  the  carpals,  tarsals,  and  vertebrae,  the 
bone  may  be  entirely  dissolved  by  interstitial  granulations  growing  all 
through  it  without  any  necessary  accompaniment  of  the  slightest 
trace  of  suppuration.^  But  in  the  great  majority  of  eases  there  is  a 
1  T.  Billroth.  2  E.  Riudfleiseh. 


158  OPERATIVE  SURGERY. 

purulent  periostitis,  especially  of  the  carpal  and  tarsal  bones,  and 
the  disease  readily  extends  to  the  entire  bone  and  its  articular  sur- 
faces as  it  progresses ;  the  sheaths  of  tendons  become  implicated, 
the  skin  ulcerates,  giving  exit  to  the  pus,  and  the  joints  swell  and 
lose  their  shape. ^  The  atonic  form  of  inflammation  with  slight 
vascularization  wliich  results  in  caseous  degeneration  of  the  new  for- 
mation, the  so-called  scrofulous  caries,  is  essentially  a  fungating 
caries.'^  It  occurs  chiefly  in  the  spongy  bones,  the  vertebraj,  the  cal- 
caneum,  and  epiphyses  of  hollow  bones,  and  readily  combines  with 
partial  necrosis.^ 

The  essential  feature  of  treatment  of  a  carious  joint  is  perfect  rest 
of  the  part,  combined  with  open  air,  syr.  ferri  iodid.  and  cod-liver 
oil.  Rest  must  be  obtained  either  by  position  or  apparatus.  In  the 
upper  extremity  both  methods  may  be  usefully  resorted  to,  but  in 
the  lower  extremity  apparatus  should  be  so  employed  as  to  prevent 
all  injurious  movements  of  the  joint,  and  yet  permit  of  that  general 
exercise  essential  to  the  health  of  tlie  patient.^  The  hip,  knee  and 
ankle-joints  may  be  placed  at  rest,  and  efficiently  protected  by  the 
gypsum  bandage,  but  well-fitted  apparatus  gives  more  precision  to 
the  efforts  to  protect  them  and  yet  allows  free  out-of-door  exercise. 
In  the  early  stage  this  course  may  secure  resolution;  later  it  may  be 
followed  by  fibrous  anchylosis,  to  be  relieved  by  flexion;  finally,  in 
the  stage  of  suppuration  it  may  result  in  bony  anchylosis.  At  various 
stages  of  progress  the  question  of  exsection  and  amputation  will  be 
raised  and  must  be  determined.  The  apparatus  necessarily  varies  at 
each  joint,  but  the  princijile  is  the  same. 

THE    HIP-JOIXT. 

At  the  hip  the  early  symptoms  are  flexion  of  the  thigh,  wasting  of 
the  limb,  pain  in  the  reirion  of  the  knee;  the  patient  may  still  exer- 
cise freely  for  months,  but  often  cries  out  at  night  from  starlings  of 
the  limb.  As  the  disease  progresses  the  thigh  becomes  everted, 
more  flexed  and  fixed,  and  the  patient  uses  the  limb  less  freely  or 
not  at  all ;  then  the  capsule  ruptures,  inversion  and  flexion  follows, 
the  head  of  the  bone  is  displaced  upwards,  and  in  this  position  an- 
chylosis occurs,  or  death  from  exhaustion.  The  long  hip  splint  should 
be  applied  as  soon  as  the  disease  is  recognized,  and  be  worn  day  and 
night  while  the  symptoms  continue.  This  splint  may  be  made  in  a 
very  inexpensive  form,  but  that  which  best  meets  all  indications  is 
made  and  applied  as  follows  :  — 

The  long  hip  splint  (Fig.  125)  extends  from  the  sole  to  the  crest  of  the  ilium, 
where  it  is  connected  to  a  pelvic  band  by  a  joint  allowing  flexion  and  exten- 

1  T.  Billroth.    2  E.  Rindfleisch.     8  H.  G.  Davis;  L.  A.  Sayre ;  C.  F.  Taylor. 


DISEASES   OF   THE  JOINTS. 


159 


sion,  abduction,  and  add  act  ion,  hut  properly  regulated.     Extciiiiion  is  made  bv 

means  of  a  rack  and  pinion  rod,  slidinfr  within  a  steel  tube,  moved  bv  a  kev, 

and  kept  in  position  hy  a  spring  caliliing  the  teeth  of  the  rack  :  counter- 
extension  is  made  by  means  of  two  perineal  pads  fastened  to  the  pelvic 
band  with  straps  and  buckles;  at  the  knee-joint  is  a 
movable  cross-piece  for  attaching  a  leather  cap  to 
steady  and  support  the  knee;  at  the  bi  tlnm  of  the  in- 
strument is  a  foot-|iiece  wiili  a  leather  sole  attached, 
to  prevent  jar  in  walking;  a  leather  strap,  passing 
under  the  foot,  through  apertures  in  the  foot-piece, 
turns  up  an  end  on  each  side  of  the  ankle,  and  fastens 
to  buckles  in  adhesive  strips,  which  prepare  as  fol- 
lows: Cut  two  pieces  of  plaster,  to  reach  from  the 
waist  to  the  foot,  from  three  to  five  inches  wide  at  the 
top,  and  from  1  to  H  inches  at  the  lower  end,  and 
divide  tops  into  five  tails,  cut  a  piece  about  five  inches 
long,  from  each  centre  tail,  and  add  it  to  the  lower 
ends  of  the  fdaster  to  strengthen  them,  then  add  two 
or  more  similar  pieces  at  the  same  place  and  attach  a 
buckle;  apply  the  plasters  against  (lie  lateral  aspects 
of  the  leg,  beginning  about  two  incites  above  the  in- 
ternal and  eiternal  maleoli  with  the  ends  having  the 
buckles  attached;  the  centre  tails  reaching  the  entire 
length  of  the  leg  and  thigh,  to  the  perineum  and  tro- 
chanter respectively;  then  wind  the  lower  ends  spi- 
rally around  the  leg  up  to  the  pelvis  and  afierwards 
the  other  two  tails,  which  first 
cut  down  to  just  above  the  knee; 
this  involves  the  limb  in  a  com- 
plete network  of  adhesive  strips, 

the  leg  having  about  one  fourth,  the  thigh  three  fourths, 

which  is  found  to  be  the  proportion  to  protect  the  leg  and 

knee  e(|ually  from  compression  or  strain;  a  few  turns  of 

roller  bandage  are  then  made  around  the  ankle,  just  under 

the  lower  ends  of  the  straps,  to  protect  the  flesh  under  the 

buckles,  and  then  continued  over  the  strips  on  the  whole 

limb;  the  patient  should  be  laid  on  his  back,  and  great  care 

ought  to  be  taken  that  the  pelvis  is  not  inclined  forward  by 

contractions  of  the  flexor  muscles;  should  this  be  the  case, 

elevate  the  leg  until  the  lumbar  vertebrae  come  near  the 

couch  and  the  spinal  column  assumes  its  normal  shape;  the 

instrument  is  then  applied;  the  pelvic  band  ought  to  be 

loose  enough  to  allow  the  pelvis  to  move  freely  in  it;  the 

anterior  superior  spine  of  the  ilium  ought  to  be  above  the 

pelvic  band  (Fig.  126);  in  applying  the  ankle  straps  leave 

a  little  space  between  the  foot  and  the  foot-piece  so  that  in 

standing  or  walking  the  weinht  of  the  patient  does  not  rest 

on  the  log,  but  on  the  instrument;  the  perineal  straps  must  Fn;.   l"2i>. 

be  so  adjusted  that  the  patient  sits  lirnily  and  comfortably  upon  tlieni;  when  the 

apparatus  is  adjusted  apply  the  key  to  the  rachet  and  extend  the  splint  until 

the  patieat  gives  evidence  that  the  strain  is  sufficient. 

1  C.  F.  Taylor. 


Fig.  125.1 


160 


OPERATIVE  SURGERY. 


Fig.  127. 


THE     KNEE-JOINT. 

At  the  knee  the  disease  causes  at  first  but  slight  symptoms  for 
months,  as  dragging  of  the  leg  or  limping,  pain  after  exercise,  or  on 
pressure;  then  there  is  swelling,  the  joint  is  evenly  rounded,  quite 
sensitive  to  pressure;  gradually  the  joint  becomes  more  and  more  an- 
gular and  painful,  so  as  to  pre- 
vent walking;  certain  points  be- 
come more  painful  and  red  with 
fever,  fluctuation  is  detected, 
and  soon  after  a  thin  pus,  mixed 
„^  with  fibrinous  cheesy  flocculi, 
I  escapes;  the  symptoms  at  first 
improve,  but  soon  another  ab- 
scess forms  with  fever;  these 
symptoms  are  repeated,  attended 
by  gradual  emaciation,  wasting 
and  flexion  of  the  limb;  the  dis- 
ease may  teri|iinate  fatally  by 
extension,  or  recovery  may  fol- 
low with  anchylosis  of  the  affected  joint.  The  knee- 
joint  may  be  very  firmly  fixed, 
and  still  allow  of  exercise  by  the 
gypsum  bandage  applied  from  the 
middle  of  the  leg  to  the  middle  F^g-  128. 

of  the  thigh.  An  eificient  brace  ^  may  be  made  of 
steel  band  and  (Fig.  127)  piece  connected  by  ex- 
tension rods,  with  rack  and  pinion  (Fig.  12<S);  or 
with  gypsum  bands  above  and  below  connected 
by  two  brackets  (Fig.  129).2 

For  the  steel  brace:  Select  adhesive  plaster,  spread  on 
strong  cloth  and  cut  it  in  strips  one  inch  wide,  and  long 
enoiigli  to  reach  from  just  below  the  knee  to  near  the 
ankle,  and  also  from  the  knee  for  several  inches  above  the 
joint,  upon  the  thigh.  Secure  those  plasters  to  within  an 
inch  of  their  extremities  by  a  snuglv-adjusted  roller  (Fig. 
128);  place  the  instrument  on  the  limb,  the  collars  fastened 
sufficiently  tight  to  be  comfortable,  and  the  loose  ends  of 
the  adhesive  plaster  turned  over  them  and  secured  by  a 

roller;  extend  the  connecting  rods  by  turning  the  kej'. 

The  gypsum  is  applied  above  and  below,  and  when  hard  the  brackets  (Fig. 

129)  are  adjusted  and  fastened  by  additional  layers. 


Fig.  129. 


THE    ANKLE-JOINT. 

Caries  attacks  the  ankle-joint  as  a  chronic  inflammation,  causing 
1  L.  A.  Sayre.  2  Q,  p.  Stilhnau. 


DISEASES   OF   THE  JOINTS. 


161 


enlargement  of  thi;  j)arts  about  the  articular 
malleoli,  with  the  final  formation  of  abscesses, 
joint.     This  joint  may  be  very  well  protected 


Fig.  130. 

tubercle  of  the  tibia,  and  placed  all  around  the  limb 
position,  to  within  an  iiicli  of  it.s  upper 
extremity,  by  a  we!l-adju.«ted  roller,  a.s 
seen  in  V'lg;.  1.30:  fix  the  instrument  and 
.•secure  the  foot  (irmly  In*  a  number  of 
strips  of  adhesive  plaster. 

In  applying  the  gypsum  brace,  the 
foot,  held  at  a  right  angle,  is  wound 
with  phjster  from  the  base  of  the  nail 
of  the  great  toe  as  far  as  the  disease, 
and  from  above  the  ankle  abnost  to  the 
knee  (Fig  131).  The  bracket  is  placed 
ill  position  anil  bound  down  by  repeated 
turns  of  the  plastered  bandage,  taking 
care  that  the  foot  is  still  at  right  angles; 
the  whole  is  neatly  covered  with  clean  fresh  bandage. 


ends  of  the  tibia,  or 
ami  exposure  of  the 
by  the  gypsum  band- 
aj^e,  applied  from 
the  toes  to  the  mid- 
dle of  the  leg.  The 
ankle-brace  may  be 
of  steel  (Fig.  130),i 
or  of  gypsum  (Fi"'. 
131).2' 

The  steel  brace  is 
applied  1  (Fig.  1.30), 
as  follows:  Cut  ad- 
hesive plaster  in 
strips  about  one  inch 
in  width  and  long 
enough  to  reach  fiom 
tiie  ankle  to  near  the 
secure  the  plaster  in  its 


Fig.  131.3 


CARPAL  AND  TARSAL  JOINTS. 

Carpal  and  tarsal  caries  is  recognized  in  its  early  stages  by  swell- 
ing and  tenderness  of  the  part,  and  later  by  the  displacement  of  the 
bones  affected  and  the  formation  of  abscesses  with  sinuses,  through 
which  the  carious  bone  is  detected.  The  general  treatment  is  tonics 
with  cod  liver  oil,  good  food,  out-of-door  exercise;  locally  tr.  iodine 
should  be  employed  with  appliances  which  maintain  perfect  rest, 
and  such  extension  as  relieves  j)ressure  upon  the  diseased  bones ;  the 
carpus    may  be  maintained  upon  a  well-j)added   palmar   splint,  with 


1  L.  A.  Savre. 


2  C.  F.  Stillman. 


8  G.  Tiemann  &  Co. 


11 


162  OPERATIVE  SURGERY. 

extension  by  adhesive  strips  applied  to  the  fingers  and  attached  to 
the  projecting  extremity  of  tlie  splint;  the  tar- 
sus is  best  immobilized  by  the  gypsum  dres- 
sing. In  advanced  caries  (Fig.  132)  setons  of 
twisted  oidiinn  ^  are  useful ;  they  have  the  ad- 
vantage of  being  disinfected  with  tar,  and  very 
porous;  make  opposite  openings,  so  that  the  setoa 
will  traverse  the  diseased  bone,  pass  the  rope 
through  and  tie  its  ends  together  over  the  part; 
every  day  or  two  fresh  oakum  should  be  twisted 
into  one  end,  then  saturated  with  bals.  Peru,  and 
di-awn  into  the  sinus.  Many  cases  will  even- 
FiG.  132.  tually  recover  under  this  treatment  persistently 

followed ;  if  it  fail  resection  or  amputation  is  a  final  necessity. 

THE    VERTEBRA. 

Spinal  caries  usually  affects  the  cancellous  tissue  of  the  verte- 
bral centre,  and  results  in  a  cheesy  metamorphosis,  beginning  in 
the  interior  of  the  mass  of  granulations  and  gradually  extending 
in  all  directions;  these  deposits,  chiefly  situated  in  the  anterior 
half  of  the  bodies  of  the  vertebra;,  soften  into  a  pus-like  fluid, 
wbith  escapes  by  stripping  off  the  periosteum,  and  the  longitu- 
dinal ligaments  of  the  column  in  front  of  which  it  accumulates, 
and  then  gravitate  downwards;  the  intervertebral  disks  either  es- 
cape the  inflammatory  changes  altogether,  or  become  involved  at  a 
relatively  late  stage  of  the  disease ;  the  result  of  the  disorganization 
is  relaxation  of  the  union  between  the  vertebrae,  which  favors  danger- 
ous displacements,  as  of  the  atlas,  and  angular  curvatures."^  The 
disease  beo'ins  very  insidiously  -with  obscure  sym])toms  referable  to 
the  nerves  of  the  affected  region;  if  in  the  lumbar  region,  there  are 
pains  in  the  legs  and  hypogastrium ;  if  in  the  dorsal  region,  the 
pains  will  be  in  the  epigastrium,  and  are  frequently  treated  as  indica- 
tions of  stomach  and  bowel  derangements ;  if  in  the  upper  cervical 
region,  the  pains  are  in  the  chest  or  back  of  the  neck  and  head.  As 
the  destructive  ulceration  progresses  there  is  increasing  weakness  of 
the  spine,  with  languor,  inability  to  stand  long  erect,  avoidance  of 
all  jarring  movements,  and  if  the  upper  cervicals  are  diseased,  a  dis- 
position to  support  and  protect  the  head  with  the  hands  applied  to 
the  chin  and  occiput;  displacement  in  the  form  of  a  sharp  posterior 
angle  next  a])pears,  revealing  positively  the  nature  of  the  affection; 
finally,  pus  gravitating  from  the  affected  vertebrae  accumulates  as  a 
'Congestive  abscess  beneath  Poupart's  ligament  or  in  the  lumbar  re- 

1  L.  A.  Sayre.  __  ^  E.  Eindfleisch. 


DISEASES   OF   THE  JOINTS. 


1(33 


<rion.  The  indications  of  treatment  are,  (1.)  improvement  of  the 
general  health;  (2.)  protection  of  the  diseased  vertebra?  from  injury; 
(3.)  management  of  spinal  abscesses.  (1.)  For  the  general  lieal^h, 
tonics  and  good  hygienic  comlitions  are  always  required.  (2.)  Pro- 
tection of  the  diseased  vertebrte  from  the  injury  which  the  super- 
incumbent weight  of  the  body  induces,  requires  judiciously  applied 
apparatus.  Of  the  various  dressings  employed  the  gypsum  bandage 
is  the  most  convenient  and  useful  in  general  practice.  It  is  designed 
to  furnish  an  immovable  apparatus  which  by  uniform  pressure 
around  the  entire  trunk  shall  sustain  the  broken  column  in  a  fixed 
position.  It  is  desirable  to  have  the  spine  extended  as  far  as  the 
curvature  will  admit  with- 
out undue  tension  of  the 
diseased  structures,  and  for 
this  purpose  the  patient 
may  be  held,  if  a  child,  by 
the  hands  in  the  axilla?,  or 
by  adhesive  strips  applied 
to  the  front  and  back  of 
the  body  and  looped  over 
the  shoulder,^  or  by  any 
means  which  secure  exten- 
sion of  the  spine,  as  lying 
face  downward,  with  shoul- 
ders and  hips  resting  on 
two  chairs,  the  body  being 
free.  But  more  perfect 
i-esults  are  obtained  by  us- 
ing a  suspending  appara- 
tus (Fig.  133)  consisting 
of  pulleys  and  cross-bar 
to  elevate  the  body  with 
an  adjusted  chin  sling,  and 
axilla?  straps.  The  gyp- 
sum dressing  is  thus  pre- 
pared and  applied:  ^ 

Select  some  loosely  woven  material,  as  mosquito  netting,  or  crinoline:  tear 
it  into  strips  three  yards  Ions?  and  two  and  a  lialf  to  three  indies  wide,  ac- 
cording to  the  size  of  the  patient;  draw  tliein  through  very  line  and  freshly 
ground  plaster  of  Paris  which  sets  quickly,  and  rub  the  plaster  well  into  the 
meshes;  roll  them  up  loosely;  apply  to  the  patient  a  tightly  fitting  shirt  of 
elastic,  soft  woven,  or  knitted  material,  without  arms,  extending  to  the  middle 
of  the  pelvis,  and  fastened  over  the  shoulder  by  talis;  apply  the  chin-piece 
of  the  apparatus,  place  the  arms  in  the  axillary  bands  and  raise  the  patient 

1  J.  A   Reed.  2  L.  A.  Savre. 


Fig.  133. 


164 


OPERATIVE   SURGERY. 


by  the  pulley  genth-  and  slowly,  and  never  beyond  the  point  at  which  he 
begins  to  feel  uncomfortable,  and  whicli  usually  admits  of  the  feet  swinging 
clear  of  the  floor ;  over  the  abdomen  between  the  shirt  and  the  skin  place 
a  pad  composed  of  cotton  folded  in  a  handkerchief  so  as  to  form  a  wedge- 
shaped  mass,  the  thin  edge  being  directed  downwards,  its  purpose  being  to 
leave  a  space  after  its  removal  when  the  bandage  is  firm  for  the  expansion 
of  the  abdomen  during  meals;  bandages,  placed  on  the  end  in  a  basin  of  water 
until  the  bubbles  cease  to  rise,  are  squeezed  until  the  surplus  water  escapes  and 
then  passed  round  and  round  the  trunk,  beginning  at  the  smallest  part,  and  ex- 
tending downwards  a  little  beyond  the  crest  of  the  ilium,  then  upwards  in  a 
spiral  direction  until  the  entire  bod}'  is  encased  from  the  pelvis  to  the  axillae; 
pads  of  cotton  are  to  be  applied  over  any  very  prominent  spinous  process  or 
other  bony  projections  which  may  be  inflamed  from  previous  pressure,  or  liable 
to  be  irritated;  if  the  patient  is  an  adult  female  place  pads  over  the  breasts  to 
be  removed  when  the  plaster  is  firm  ;  the  bandage  should  be  placed  smoothl}' 
but  not  tightly  round  the  body,  being  simply  unrolled  with  one  hand  and 
smoothed  so  as  to  be  adapted  to  all  the  irregularities  by  the  other;  after  one  or 
two  thicknesses  have  been  applied,  narrow  strips  of 
roughened  tin  or  zinc  should  be  placed  on  either  side 
and  parallel  with  the  spinous  processes,  and  others 
added  at  intervals  of  two  or  three  inches  until  they 
surround  the  body;  over  these  apply  another  bandage; 
the  plaster  sets  rapidly,  and  the  patient  may  soon  be 
taken  from  the  apparatus  and 
laid  upon  a  hair  mattrass;  the 
pad  must  be  removed  from 
the  abdomen  and  the  bandage 
pressed  firmly  about  anteri- 
or superior  spines  and  from 
the  breasts  when  used,  and 
compression  made  against  the 
sternum  to  fix  the  part  firmly; 
if  the  bandage  is  weak  at  any 
point  wet  the  part  and  dust 
it  with  plaster  (Fig.  134).  The  abdominal  pad  may 
be  dispensed  with,  and  firm  support  given  by  the  ban- 
dage to  the  lower  part  of  the  region,  if  an  opening  is 
cut  in  the  dressing,  corresponding  with  the  stomach, 
after  the  bandage  is  firm  (Fig.  135). i  Additional  fen- 
estraeare  often  required  as  at  the  curvature,  or  where  sinuses  are  discharging. 

The  compensative  curves  of  the  spine  may  be  more  completely  straightened 
b}'  inducing  profound  anesthesia  before  suspension,  and  experience  proves  that 
there  is  no  danger  during  anaesthesia,  either  in  the  position  of  the  patient  or  in 
the  compression  of  the  tliorax  by  the  gypsum,  even  if  the  patient  remains 
suspended,  as  is  usual,  until  the  dressing  becomes  firm. 2 

If  the  diseased  vertebrae  are  in  the  lumbar  or  lower  dorsal  reqjions 
the  bandaije  need  not  be  applied  higher  than  the  axillaj,  but  if  the 
caries  exist  in  the  upper  dorsal  region  there  must  be  additional  sup- 
port of  the  upper  part  of  the  thorax,  and  this  is  obtained  by  continu- 
ino-  the  bandage  over  the  shoulders,  and  thus  encasing  the  entire 


Fig.  134. 


Fig.  135. 


1  Bellevue  Hosp.  Records. 


2  Von  Langenbeck. 


DISEASES   OF   THE  JOINTS. 


165 


trunk  in  the  common  dressing  (Fig.  135).  When  this  form  is  used 
the  arms  must  not  be  in  the  sling  but  should  hang  by  the  side.  By 
this  means  the  spine  can  be  permanently  maintained  erect.  When 
the  caries  attacks  the  cervicals,  means  must  be  used  to  so  support  the 
head  that  the  conti;_'uoiis  vertebra;  may  not  be  compressed.  This  may 
be  accomplished  by  supporting  the  chin,  or  by  lifting  the  head  entire. 
The  chin  may  be  sustained  by  extending 
the  plaster  of  Paris  jacket  (Fig.  135)  up- 
wards as  a  cravat,  well  lined  with  cotton 
batting,  or  other  soft  material  (Fig.  136). 
Or,  the  head  may  be  raised  entirely  from 
the  cohnnn  by  an  appliance  (Fig.  137)  so 
incorporated  in  the  plaster  bandage  that 
it  has  a  firm  basis  of  support,  and  by  a 
sling  which  accurately  fits  the  chin  and 
occiput  and  lifts  the  head  directly  up- 
wards (Fig.  137).  Yio.  i;i6. 

To  apply  the  apparatus  the  patient  is  suspended  in  the  usual  way,  from 
the  axillu;,  chin,  and  occiput,  and  the  plaster  bandage  applied,  as  usual, 
over  a  tight-fitting  knit  or  woven  shirt.  After  the  bandage  has  been  accu- 
rately applied,  the  patient  is  removed  from  the  suspending  apparatus  and 
carefully  laid  upon  an  air  bed  until  the  plaster  has  hardened  or  "  set."  The 
patient  can  then  stand  up,  and  the  apparatus  for  sus- 
pending the  head  is  applied  in  its  proper  ))osition, 
over  the  hack  of  the  pla-iti.T  jacket,  and  the  lower  por- 
tion of  it  bent  and  moulded  until  it  accurately  fits  all 
its  various  curves.  The  loose  tin  strips,  being  veiy 
flexible,  can  then  be  smoothly  moulded  around  the 
jacket  which  has  already  been  applied  to  the  trunk, 
and  another  plaster  bandage,  having  been  wetted  in 
water,  is  to  be  carefully  and  tightly  applied  over  the 
apparatus  and  jacket  first  applied,  in  sufficient  num- 
ber of  layers  to  make  it  perfectly  secure.  The  tin  being 
rough  and  perforated,  a  sufficient  amount  of  plaster 
will  be  incorporated  into  its  holes  and  meshes  to  pre- 
vent any  possibility  of  displacement.  We  have  now  a 
secure  point  of  support  from  the  pelvis  and  trunk,  and 
the  head  can  be  sustained  by  properly  adjusting  the 
movable  rod  and  securing  it  by  screws. 

The  gypsum  dressing  may  be  worn  without 
change  from  two  weeks  to  two  months,  accord- 
ing to  the  effect  which  it  produces;  when  renewed,  the  patient 
should  be  thoroughly  washed,  but  without  assumins  the  upright  posi- 
tion. The  final  cure  is  rarely  completed  in  the  most  successful  cases 
in  one  year. 

There  are  several  kinds  of  useful  apparatus  for  spinal  caries  more 
or  less  complicated  in  their  mechanism,  and  re(juiriiig  great  experi- 
ence and  care  in  their  successful  management. 


Fig.  137. 


166 


OPERATIVE  SURGERY. 


A  very  neat  and  efficient  spring  corset  l  ma}-  be  so  constructed  and  applied 
as  to  protect  the  diseased  vertebra  from  injurv,  and  allow  great  freedom  of  mo- 
tion of  the  trunk;  the  springs  are  brass,  of  a  serpentine  form,  especially  tem- 
pered, elastic  and,  by  a  little  manipulation,  readily  adapted  to  any  surface,  how- 
ever irregular  or  uneven,  to  which  thev  are  applied;  in  tiieir  spring-like  action 
exists  an  elevating  power,  an  auxiliarj'  to  the  local  and  general  support  rendered, 
the  tendency  of  which  is  to  take  oft"  the  superincumbent  weight  of  the  body 
from  the  diseased  vertebrae. 

A  spinal  brace  ^  may  be  so  applied  as  to  take  the  weight  of  the  trunk  above 
the  point  of  disease  from  the  bodies  of  the  vertebra;  and  throw  it  on  the  articu- 
lar processes.  There  are  two  pieces  or  levers  passing  up  the  back,  not  over  the 
spine,  but  each  side  of  it,  so  that  it  is  firmly  held 
from  lateral  deviations;  to  the  upper  end  of  these, 
two  curved  pieces  of  steel  are  fastened  diagonally 
on  both  sides  of  the  neck;  they  pass  directly  for- 
ward and  around  the  shoulder,  and  thus  prevent  a 
great  loss  of  force  by  diagonal  action.  This  ar- 
rangement entirely  obviates  the  painful  and  inju- 
rious ligaturing  of  the  arms,  which  would  occur  if 
the  straps  passed  forward  from  one  point.  At  the 
part  opposite  the  point  of  disease,  the  point  where 
the  fulcrum  pads  are  placed  is  made  of  chamois 
skin  or  (Janton  flannel,  tilled  with  cork  filings, 
which  have  no  felting  qualities,  or,  if  desirable, 
can  also  be  made  of  hard  rubber;  the  shoulder- 
straps  and  the  band  around  the  hips  are  likewise 
provided  with  similar  pads  to  protect  tiie  skin  from 
pressure  and  abrasion;  the  instrument,  like  the 
spine  itself,  acts  like  a  double  lever  with  a  common 
fulcrum  at  the  curvature;  this  action  is  directly 
backward  at  the  hips  and  shoulders  and  directly 
forward  at  the  middle  of  the  back,  or  wherever  the 
diseased  part  is  located;  thus  the  posterior  portion, 
the  onlv  healthy  portion  of  the  diseased  vertebrae, 
is  made  to  support  a  part  of  the  weight  of  the  body  and  the  intervertebral  car- 
tilage and  bodies  of  the  vertebr.t,  where  the  disease  exists,  are  relieved  of  pres- 
sure. The  abdomen  is  still  further  sustained  in  the  upward  direction  b}'  an 
apron  in  front  which  is  fastened  on  each  corner.  If  the  disease  is  in  the  upper 
dorsal  or  cervical  region,  an  apparatus  is  constructed  for  such  cases  with  an 
attachment  for  sustaining  the  head ;  the  effect  and  form  of  this  attachment 
is  that  of  a  lever,  acting  backwards  to  raise  the  head  and  neck. 

3.  Spinal  abscesses, ^  whether  they  appear  in  the  hinibar  region  or 
below  Poupart's  ligament,  should  be  opened  antiseptically,  as  fol- 
lows: While  the  spray  covers  the  region  of  incision,  make  a  suffi- 
ciently free  opening  at  the  most  dependent  part  to  allow  of  the  com- 
plete escape  of  the  contents;  after  the  pus  has  ceased  to  flow  inject 
carbolic  solution  thoroughly  into  all  parts  until  the  fluid  returns 
clear;  with  the  last  injection  cause  hyperdistention  of  the  cavity  by 
holding  the  edges  of  the  wound  firmly  to  the  nozzle  while  the  fluid  is 
1  J.  A.  Wood.  2  c.  F.  Taylor.  3  j.  Uster. 


Fig.  138. 


DISEASES  OF  THE  JOINTS.  1G7 

injecte<l;  if  tlie  dt-ep  sinus  tan  be  found  pass  a  tube,  as  a  catheter,  as 
far  as  practicable  without  injurinji  the  parts,  and  llirow  the  injection 
as  nearlv  as  possible  up  to  the  carious  vertebrae;  insert  two  or  tliree 
drainage   tulies,  rubber  tubes  with  holes  cut  in  at   ditTerent   jioints 


Fig.  139. 

(Fig.  139),  and  cover  with  the  gauze  or  carboHzed  dressings  ;  change 
these  dressings  under  spray  as  often  as  the  discharges  recjuire,  wash- 
ing the  cavity  out  with  carbolic  solutions  wlienever  there  is  any  indi- 
cation of  putrid  matters  present;  continue  these  dressings  until  the 
abscess  has  closed  or  is  reduced  to  the  condition  of  a  sinus.  Treated 
in  this  manner,  spinal  or  other  congestive  abscesses  may  be  freely 
opened,  their  contents  removed,  and  a  healthy  granulating  surface 
established  and  the  sinus  often  closed  without  incurring  the  ordinary 
risks  of  profuse  suppuration  and  systemic  poisoning. 

If  antiseptics  are  not  employed,  the  following  advice  cnnnot  be  too  carefully 
lieede<l :  If  the  abscess  conies  from  a  bone  on  which  an  operation  is  impossible 
or  undesirable,  do  not  meddle  with  it,  but  be  thankful  for  every  day  that  it  re- 
mains closed,  and  wait  quietly  until  it  opens,  for  thus  there  will  be  relatively 
the  least  danger,  i 

III.    LOOSE  BODIES. 

These  bodies  in  the  knee-joint  are  outgrowths  of  cartilages  in 
chronic  rheumatic  arthritis,  or  in  the  dendritic  growth  of  synovial 
fringes  accidentally  detached,  or  portions  of  the  proper  articular  car- 
tilage with  or  without  some  subjacent  bone  which  has  been  exfoli- 
ated into  the  joint.'^  The  symptoms  are  sliglit  pain  in  knee  with 
weakness,  and  often  moderate  dropsy,  and  at  length  sudden  pain 
and  inability  to  walk  while  the  knee  stands  between  th-xion  and  ex- 
tension, due  to  the  loose  body  being  caught  between  the  bones  form- 
ing the  joint,  or  the  semilunar  cartilatres,  or  in  one  of  the  synovial 
sacs;  it  may  at  times  be  detected  and  fi.xed  by  external  manipulation.' 
When  very  troublesome,  it  must  be  removetl  by  the  antiseptic  method 
under  the  spray;  fix  the  body  as  firndy  as  possible  and  make  a  free 
incision  upon  it;  apply  the  antiseptic  dressing  and  secure  ])erfect rest; 
if  there  is  much  effusion,  drainage  tubes  should  be  introduced.*  If 
antiseptics  are  not  used,  the  utmost  care  must  be  taken  to  protect 
the  joint  from  the  entrance  of  air;  force  the  body  tightly  under  the 
skin  at  one  side  of  the  joint,  press  the  skin  strongly  upward,  and 
put  it  still  more  on  the  stretch,  then  cut  through  the  skin  and  cap- 
sule down  upon  the  body,  and  let  the  latter  spring  out,  or  lift  it  out 
1  T.  Billroth.  2  Sir  J.  Paget.  3  j.  Lister. 


168  OPERATIVE  SURGERY. 

with  an  elevator ;  instantly  close  the  wound  with  the  finger,  extend 
the  leg,  let  the  skin  return  to  its  normal  position  so  that  the  cut  in 
it  lies  lower  than  in  the  capsule,  and  the  two  wounds  do  not  commu- 
nicate directly;  close  the  skin  wound  with  sutiu-es  and  plasters;  ex- 
tend the  limb  on  a  splint,  or  apply  the  gypsum  dressing  before  the 
operation,  and  make  a  large  opening  over  the  joint.^  The  sub- 
cutaneous incision  may  be  made,  and  the  body  forced  into  the  con- 
nective tissue,  where  it  is  allowed  to  remain  or  is  subsequently  re- 
moved. 


CHAPTER  XVII. 
GENERAL  OPERATIONS  ON  THE  JOINTS. 

1.    EXCISION. 

The  excision  of  a  joint  is  the  more  or  less  complete  removal  of  the 
articular  surfaces  of  the  bones  which  enter  into  its  formation. 

1.  The  indications  for  the  necessity  of  excision  are:  for  shot  in- 
juries, the  comininntion  of  the  joint  ends  of  the  bones,  or  the  impac- 
tion of  a  ball  in  the  end  of  the  bone  in  such  manner  that  it  cannot 
be  removed  without  destruction  of  the  bone  ;  in  compound  disloca- 
tion with  extensive  injury  of  tlie  soft  parts,  or  complicated  with 
fracture;  in  caries  which  lias  destroyed  the  articular  surface,  and 
continues  to  progress  in  spite  of  well-directed  efforts  to  control  it. 

2.  The  time  of  excision  should  be  immediate  in  all  injuries  which 
undoubtedly  necessitate  its  performance,  but  for  caries  it  should  be 
delayed  until  tlie  appropriate  measures  for  its  arrest  liave  been  thor- 
oughly applied  without  success. 

3.  The  method  of  operation  should  aim  (1.)  to  remove  all  diseased 
structures  without  needlessly  sacrificing  parts;  in  children,  especially, 
the  epiphyses  of  bones  must  be  preserved  with  the  most  scrupulous 
care,  to  insure  their  future  growth;  in  adults  the  amount  of  bone  re- 
moved will  always  have  regard  to  the  future  usefulness  of  the  joint; 
(2.)  to  preserve  the  functions  of  the  joint;  the  fibrous  structures 
which  strengthen  must  be  saved  in  their  proper  relations;  the  peri- 
osteum must  be  j)reserved  with  the  attachments  to  the  capsule  ;  the 
muscular  attachments  must  be  separated  uninjured,  or  wiih  the  bony 
fragments  of  their  insertions  to  insure  their  future  usefulness ;  the 
bones  must  be  so  shaped  and  placed  in  position  as  to  maintain  their 
special  movements,  preserving  even  a  useful  hinge-joint  at  the  el- 
bow 2  and  at  tlie  knee.* 

1  T.  Billroth.  2  II.  .J.  BiKelow.  3  c.  Hiiter. 


OPERATIONS  ON  THE  JOINTS.  169 


JOINTS    OF    THE    UPPER    LIMBS. 

1.  The  phalangeal  joints  should  be  excised  by  an  incision  along 
the  side,  sli^litly  convex  downwards;  tlirough  a  single  incision  the 
extremities  of  the  bones  may  often  be  reached  and  excised  by  turn- 
ing them  outwards.  In  the  treatment  make  sufficient  extension  by 
means  of  a  palmar  splint  to  keep  the  hones  apart,  and  begin  passive 
flexion  as  soon  as  repair  is  established. 

2.  The  metacarpophalangeal  joints  should  be  excised  by  dor- 
sal incisions  along  the  margin  of  the  extensor  tendons,  which  must 
be  drawn  one  siile;  the  articular  surfaces  being  cleared,  excise  them 
with  cuttinii;  forceps,  a  fine  saw,  or  cliaiu  saw.  The  treatment  is  the 
same  as  after  excision  of  the  phalangeal  joints. 

3.  The  -wrist  joint  is  properly  limited  to  the  articular  end  of  the 
radius,  and  the  first  row  of  carpals.  But  excision  at  the  wrist  in- 
cludes the  removal,  not  only  of  the  radius  and  first  row  of  carpal 
bones,  but  of  a  part  or  whole  of  the  ends  of  the  radius  and  ulna,  a 
part  or  whole  of  the  carpus,  the  proximal  ends  of  the  metacarpal 
bones,  or  all  of  these  at  once.^ 

The  radio-carpal  articulation  is  formed  between  the  radius  and  triangular  tibro- 
cartilage  above,  and  tlie  scapiioid,  semilunar,  and  cuneiform  bones  below;  the 
carpal  articulations  are  arthrodial;  the  synovial  sacs  are  so  arranged  that  their 
communications  are  limited;  this  anatomical  peculiarity  should  be  remembered 
in  the  effort  to  remove  portions  of  the  carpus,  as  it  is  desirable  not  to  open  these 
cavities  farther  than  is  absolutely  necessar}';  the  ligaments  are  dorsal,  palmar, 
and  interosseous. 

In  the  radiocarpal  and  common  carpal  articulation,  there  is  allowed 
not  only  flexion  and  extension,  but  a  certain  amount  of  lateral  bend- 
ing.2 

The  per  cent,  of  mortality  of  all  exsections  at  the  wrist  is,  for  disease,  7;  and 
for  shot  injuries,  15:  the  per  cent,  of  usefulness  of  the  wrist  in  the  cases  which 
have  given  determined  results  is,  for  disease,  7  perfect,  45  useful,  and  24  worth- 
less; for  injuries,  28  perfect,  and  57  useful  ;  for  shot  injuries,  1  perfect,  28  use- 
ful, and  17.5  worthless,  or  requiring  amputation;  the  effect  of  the  extent  of  ex- 
cision upon  the  per  cent,  of  usefulness  is,  for  partial  G2.9,  and  for  complete  83.3 
The  following  are  the  detinite  end  results  after  various  excisions  for  shot  in- 
juries at  the  wrist;*  in  five  complete  excisions  the  functions  of  the  hand  were 
much  impaired,  but  preferable  to  amputation  ;  in  four  excisions  of  the  extremities 
of  radius  and  ulna,  there  was  lateral  distortion  of  hand  and  stiffness  of  tingers; 
in  twenty-one  excisions  of  the  lower  end  of  the  radius  nearly  all  had  anchylosis 
and  extreme  deformity;  the  hand  generally  being  strongly  deflected  to  the  ra- 
dial side,  often  at  right  angles,  the  fingers  rigidly  fixed  in  fiexion  or  extension, 
the  end  of  tlie  ulna  projecting,  and  the  integument  over  it  irritated  and  exposed 
to  accidental  injuries;  in  fourteen  excisions  of  the  ulna,  nearly  all  had  anchylo- 
sis and  deformit}',  the  hand  was  generally  less  displaced,  but  there  was  an  equal 

1  R.  M.  Hodges.        2  Quain's  Auat.        8  H.  Culbertson.        *  g.  A.  Otis. 


170  OPERATIVE  SURGERY. 

proportion  of  cases  of  ridigity  of  the  fingers,  and  more  examples  comparatively 
of  paralysis  and  of  neuralgic  suffering;  in  six  cases  of  excision  of  the  end  of  the 
radius  with  one  or  more  carpals,  there  was  anchylosis  and  deformity;  in  eight 
cases  of  excisions  of  the  end  of  the  ulna  with  adjacent  carpals,  or  carpals  and 
metacarpals,  two  had  verj'  useful  hands,  but  the  remainder  had  anchylosis,  con- 
tracted lingers,  and  other  deformities:  in  eight  exci>ions  confined  to  the  carpus, 
three  retained  valuable  mobility  of  the  hand,  and  five  had  anchylosis  with  much 
deformit}' ;  from  this  record  it  seems  probable  that  recovery  unattended  by  an- 
chylosis is  seldom  to  be  anticipated,  yet  that  this  result  is  not  disastrous  provided 
the  hand  is  in  good  position,  and  the  functions  of  the  fingers  are  in  some  degree 
preserved.  But  these  imperfect  extremities  are  far  more  useful,  especially  when 
supported  by  suitable  apparatus,  than  stumps  after  amputation. ^ 

Excision  for  caries  has  hitherto  been  unsuccessful  chiefly  owing  to  the  I'ecur- 
rence  of  the  disease,  and  the  impaired  functions  of  the  hand;  but  these  results 
are  largelv  due  to  partial  excisions,  and  hence  the  necessity  of  complete  removal 
of  the  wrist  when  affected  with  caries.  Even  bones  which  appear  sound  in 
a  carious  joint  seem  apt  to  be  affected  in  an  insidious,  incipient  degree,  and  if 
left  behind  may  lead  to  recurrence  of  the  complaint. 2 

The  indications  for  excision  are;  for  shot  injuries,  if  there  is  com- 
minution of  the  bones  of  the  carpus,  or  of  the  carpus  and  epiphy- 
ses of  the  bones  of  the  fore-arm,  especially  if  the  missile  is  lodged, 
and  cannot  be  removed  otherwise;  if  subsequently  infiltration  cannot 
be  controlled  by  incision  and  threatens  to  spread  to  the  fore-arm  ;3 
in  injuries,  as  compound  dislocations,  all  displaceil  and  fractured 
bones  which  must  eventually  become  detached  should  be  at  once  re- 
moved ;  in  crushing  injuries  when  vessels,  nerves,  and  soft  parts  are 
not  so  much  involved  as  to  render  amputation  necessary  ;  in  sec- 
ondary excisions  for  injuries  to  the  carpus  the  entire  wrist  should  be 
removed;  in  caries  involving  the  carpus  extensively,  and  which  has 
resisted  other  treatment,  excision  becomes  necessary. 

Excision  of  the  entire  wrist  consists  of  a  series  of  operations  each 
of  which  must  be  executed  with  scrupulous  care,  as  follows:-  Break 
down  adhesions  of  tendons  by  freely  moving  all  the  articulations  of 
the  hand ;  commence  the  first  incision  at  the  middle  of  the  dorsal  as- 
pect of  the  radius,  2  (Fig.  140),  on  a  level  with  the  styloid  process  ; 
carry  it  towards  the  inner  side  of  the  metacarpo-phalangeal  articula- 
tion of  the  thumb,  running  parallel  in  this  course  to  the  extensor 
secundi  internodii  ;  on  reaching  the  line  of  the  radial  border  of  the 
second  metacarpal  bone,  carry  it  downwards  longitudinally  half  the 
length  of  the  bone,  the  radial  artery  lying  farther  to  the  outer  side 
of  the  liinb;  detach  the  soft  parts  from  the  bone  at  the  radial  side  of 
the  incision,  the  knife  being  guided  by  the  thumb  nail;  divide  the 
tendon  of  the  extensor  carpi  radialis  longior  at  its  insertion  into  the 
base  of  the  second  metacarpal  bone,  and  raise  it  along  with  that  of 
the  extensor  carpi  radialis  brevior  previously  cut  across,  and  the  ex- 

1  E.  D.  Hudson.  2  j.  Lister.  3  Von  Langenbeck. 


OPERATIONS   OX  THE  JOINTS. 


171 


tensor  secundi  internodii  while  the  radial  i.<  thrust  somewhat  out- 
wards ;  separate  the  trapezium  from  the  rest  of  tl»e  carpus  by  cutting 
forceps  applied  in  the  line  with  the  longitudinal  part  of  the  incision; 
leaving  the  trapezium  in  po- 
sition until  the  rest  of  the 
carpus  is  taken  away,  dissect 
the  soft  parts  on  the  ulnar 
side  of  the  incision  from  the 
carj)us  as  far  as  convenient, 
the  hand  being  bent  back  to 
relax  the  extensor  tendons  of 
the  fi niters;  commence  the 
second  incision,  3  (Fig.  140), 
at  least  two  inches  above  the 
end  of  the  ulna,  immediately 
anterior  to  the  bone,  and 
carry  it  downwards  between 
the  bone  and  flexor  carpi  ul- 
naris,  and  on  in  a  straight 
line  as  far  as  the  middle  of 
the  fifth  metacarpal  bone  on 
its  palmar  aspect ;  raise  the 
dorsal  lip,  cut  the  extensor 
carpi  nlnaris  at  its  insertion 
into    the     fifth     metacarpal  Fig.  140. 

bone,  and  dissect  it  from  its  groove  in  the  ulna  wiihout  isolating  it 
from  ;he  integuments  ;  separate  the  extensors  of  the  fingers  from 
the  carpus,  and  divide  the  dorsal  and  internal  lateral  ligaments  of  the 
wrist-joint ;  leave  the  connections  of  the  tendons  with  the  radius 
undisturbed;  now  clear  the  anterior  surface  of  the  ulna  by  cutting 
towards  the  bone,  avoiding  the  artery  and  nerve;  open  the  articulation 
of  the  pisiform  bone,  and  separate  the  flexor  tendons  from  the  carpus, 
the  hand  being  depressed  to  relax  them  ;  clip  through  the  base  of  the 
process  of  the  unciform  bone  with  pliers,  but  avoid  carrying  the  knife 
farther  down  the  hand  than  the  bases  of  the  metacarpal  bones; 
divide  the  anterior  ligament  of  the  wrist-joint,  separate  the  carpus 
from  the  n\et;>carpus  with  cutting  pliers,  and  extract  the  carpus  with 
sequestrum  force[)s  through  the  ulnar  incision,  dividing  any  ligament- 
ous attachments;  the  articular  ends  of  the  radius  and  ulna  may  be 
protruded  at  the  ulnar  incision  and  excised;  divide  the  ulna  obliquely 
with  a  small  saw  so  as  to  take  away  the  cartilage-covered  roundeil 
part  over  which  the  radius  sweeps  while  the  base  of  the  styloid  pro- 
cess is  retained ;  clear  the  radius  sufficiently  to  remove  the  articular 
surface;  if  the  caries  is  sli;iht  remove  a  thin  slice  without  disturbing 


172 


OPERATIVE  SURGERY. 


the  tendons  in  their  grooves  on  the  back  of  the  bone ;  clip  away  the 
articular  facet  of  the  ulna  with  bone  forceps  applied 'longitudinally; 
if  the  caries  is  extensive  remove  freely  all  the  diseased  bone  with 
pliers  and  gouge  ;  examine  the  metacarpal  bones  and  excise  the  artic- 
ular SLU-faces  only  if  they  are  sound,  and  more  extensively  if  diseased; 
next  seize  the  trapezium  with  strong  forceps,  and  dis.<ect  it  out  with- 
out cutting  the  tendon  of  the  flexor  carpi  radialis,  and  excise  the  end 
of  the  metacarpal  bone;  clip  off  the  articular  facet  of  the  i)isiforni 
bone,  and,  if  sound,  leave  the  remainder  in  position;  close  the  radial 
incision  firndy  throughout  with  sutures,  and  also  the  ends  of  the 
ulnar  incision;  but  the  middle  must  be  kept  open  by  pieces  of  lint  in- 
troduced lightly  to  give  support  to  the  extensor  tendons,  and  afford 
free  escape  of  pus. 

The  incision  i  may  be  made  from  the  middle  of  the  idnar  border  of  the  meta- 
carpal bone  of  the  index  tin^^er  upwards  to  the  middle  of  the  dorsal  surface  of 
the  epiphyses  of  the  radius,  l(Fig.  141),  crossing  to  the  ulnar  side  of  the  extensor 

carpi  ulnaris  at  its  insertion  into  the 
base  of  the  third  metacarpal  bone,  and 
dividing  the  dorsal  ligament  of  the  car- 
pus between  the  tendons  of  the  long 
extensor  of  the  thumb,  and  the  exten- 
sor indicis;  the  soft  parts  being  raised 
through  this  incision  by  careful  manipu- 
lation of  the  hand,  the  carpal  bones  may 
be  removed  one  bj'  one  by  dividing  the 
ligaments  which  bind  them  together 
and  to  other  bones. 

Various  other  methods  of  partial  and 
complete  excision  have  been  devised 
(Fig.  141).  A  common  method  has 
been  by  parallel  incisions,  one  on  the 
radial,  6,  and  the  other  on  the  ulnar 
border,  e,  joined  b}-  a  transverse  incis- 
ion on  the  dorsum  of  the  carpus. 2  The 
great  defect  in  this  method,  as  in  simi- 
lar incisions,  variously  curved,  c  and/*, 
is  that  the  extensor  tendons  are  sacri- 
ficed; though  these  incisions  may  be 
adopted  in  exceptional  cases,  they  do  not  offer  the  advantages  of  the  method  ^ 
given. 

The  after  treatment  ^  must  be  pursued  with  due  recognition  of  the 
fact  that  the  new  joint  at  the  wrist  is  produced  by  an  approximation 
of  the  bones  of  the  fore-arm  and  of  the  metacarpus,  partly  by  short- 
ening of  the  limb  and  partly  by  the  growth  of  new  bone  from  the 
divided  ends;  with  proper  care,  perfect  symmetry  of  the  hand  can 
always  be  insured;  for  as  the  radius  and  ulna  above,  and  the  meta- 
1  Von  Langenbeck.  2  Sir  \Y.  Fergusson.  3  J.  Lister. 


OPERATIONS   ON  THE  JOINTS. 


173 


Fig.  142. 


carpus  below,  are  divided  in  parallel  lines,  the  slirinkinr^  of  the  new 
material  between  them  draws  the  hand  ecpially  upwards  towards  the 
forearm;  the  surgeon  should  aim  to  maintain  tle.xibility  of  the  fingers 
by  fre<iuently  moving  them,  and  at  tlie  same  lime  to  procure  firm- 
ness of  the  wrist  by  keeping  it  securely  fixed  during  the  process  of 
consolidation.  These  indications  are  met  by  placing  the  limb  on  the 
splint  (Fig.  142),^  which 
consists  of  an  obtuse- 
angled  jiiice  of  thick  cork 
attached  to  a  splint,  with 
a  cross-bar  of  cork  at- 
tached to  the  under  sur- 
face al)Out  the  level  of 
the  knuckles  ;  on  the 
splint  the  hand  lies  semi- 
flexed, its  natural  posi- 
tion, the  fingers  midway 
between  the  extremes  of 
flexion  and  extension  into 
which   it   is    necessary  to 

bring  them  in  the  daily  passive  movements;  the  thumb  is  to  be  kept 
from  the  index-finger  by  a  pad  of  cotton  maintained  between  them; 
flexion  and  extension  of  the  fingers  should  be  commenced  on  tlie 
second  day,  whether  inflammation  has  subsided  or  not,  and  con- 
tinued daily,  each  finger  bein'^  flexed  and  extended  to  the  fullest  de- 
gree possible  in  health,  c.ire  being  taken  that  the  metacarpal  bone 
concerned  is  held  steady;  pronation  and  supination  must  not  be  neg- 
lected, and  as  the  wrist  acquires  firmness,  flexion  and  extension,  ad- 
duction and  abduction,  should  be  occasionally  encouraged;  passive 
motion  must  be  continued  until  there  is  no  longer  9,  tendency  to  con- 
tract adhesions.^ 

2.  The  elboTV-joint  has  two  motions,  flexion  and  extension, 
which  are  limited  to  the  locking  of  the  coronoid  and  olecranon  pro- 
cesses in  the  respective  fossoB  of  the  humerus  which  receive  them  ; 
the  path  of  motion  is  in  nearly  a  vertical  plane  with  a  direction 
slightly  outwards;  the  inner  lip  of  the  trochlea  being  prominent  be- 
low, forms  an  expansion  which  corresponds  to  an  inward  projection 
of  the  coronoid  part  of  the  ulnar  surface,  and  is  only  brought  into 
use  in  flexion;  the  outer  lip  of  the  trochlea  being  everted  at  the  upper 
and  back  part,  forms  a  surface  which  is  only  in  use  in  complete  ex- 
tension, and  which  then  corresponds  to  a  surface  on  the  outer  aspect 
of  the  olecranon,  which  comes  in  contact  with  no  other  part  of  the 
humerus ;  in  flexion  and  extension,  the  radius  moves  by  its  cup- 
1  J.  Lister. 


174  OPERATIVE  SURGERY. 

shaped  head  upon  the  ca|5itiihmi,   and  on  the  groove  between  that 
process  and  the  trochlea  by  a  ridge  internal  to  the  cup.^ 

The  per  cent,  of  mortality  from  excision  for  shot  injuries  is  19,  for  injin-ies  15, 
for  disease  10;  for  deformity,  no  deaths  in  13  cases;  for  all  classes,  15.69  per 
cent,  in  1.075  cases. •^  The  results  of  other  treatment  ma}'  be  thus  stated:  for 
shot  injuries  the  expectant  plan  gives  deaths  10.3  per  cent. ;  amputation  in  the 
arm,  24.3  percent.;"*  for  injuries,  amputation  of  the  arm  gives  34  per  cent.;* 
and  for  disease,  26  per  cent,  mortality. ^  Complete  excision  is  more  favorable  to 
life  than  partial,  in  shot  injuries  and  disease,  the  per  cent,  of  mortality  of  the 
former  being,  for  shot  injuries,  25;  for  diseases,  9  ;  the  latter,  for  shot  injuries, 
26.7;  for  diseases,  11;  for  injuries  proper,  entire  excision  is  more  fatal  than 
partial,  the  mortality  being,  for  the  former,  21  per  cent.,  and  for  the  latter  7.4 
percent.;  of  the  vigorous  33,  of  the  exhausted  66  percent,  die  after  excision; 
the  most  favorable  age  is,  for  shot  injuries,  20-25  ;  for  injuries,  30-40;  for  dis- 
ease, 10-20;  the  most  favorable  period  is,  for  injuries,  the  primary,  and  for 
disease,  between  9-12  months  from  the  origin. 2 

The  usefulness  of  the  joint  after  excision  depends  upon  the  perfec- 
tion of  the  hinge,  or  antero-posterior  motion.  The  extreme  conditions 
in  which  it  may  be  left  are  anchylo.sis,  and  a  flail-like,  or  dangle-joint 
action.  Though  in  both  cases  the  limb  is  often  very  useful,  yet 
every  effort  should  be  made  to  avoid  such  results.  While  it  is  true 
that  after-treatment  has  much  to  do  with  the  prevention  of  anchy- 
losis, yet,  in  general,  the  extent  of  exsection  determines  the  degree 
of  mobility,  and  also  the  power  of  controlling  it ;  if  too  little  is 
taken  away  there  will  be  more  or  less  complete  anchylosis,  and  if 
too  much,  there  will  be  such  relaxation  of  the  muscles  as  to  prevent 
their  efhcient  action;  excisions  which  have  given  the  best  results 
have  been  at  the  commencement  of  the  condyloid  projections  of 
the  humerus,  and  at  the  base  of  the  coronoid  process  of  the  ulna.® 
The  periosteum  should  be  carefully  preserved,  whatever  method  is 
adopted.  It  may  be  established  as  a  rule,  that  excision  for  injury 
should  be  partial  and  conservative,  and  for  disease  it  should  be 
entire,  or  limited  only  by  the  removal  of  the  diseased  bone.® 

When  the  disease  or  injury  is  limited,  it  is  of  doubtful  propriety  to  inflict  ad- 
ditional injury  by  section  of  healthy  bone,  for  excellent  results  have  been  ob- 
tained when  the  joint  ends  of  either  the  upper  or  fore-arm  have  been  removed 
after  complete  exposure  of  the  joint,  and  the  uninjured  portions  of  the  articula- 
tion have  been  unmolested. ^ 

The  method  of  operation  maybe  by  an  incision  made  longitudinally, 
or  by  the  H,''  the  T,8  the  I-  ,  the  H,  the  -|-  shaped.  The  results, 
both  as  to  mortality  and  usefulness,  prove  that  absolute  preference 
should  not  be  given  to  either  method  in  all  cases,  but  that  the  in- 
cision should  be  selected  on  anatomical  grounds,  or   in  relation   to 

1  Quain's  Anatomy.        2  h.  Culbertson.        3  Q,  A.  Otis.        *  S.  D.  Gross. 

5  J.  E.  Erichsen.  6  c.  Hiit^r;  Von  Langenbeck.  ^  Moreau. 

8  J.  Roux. 


oPEiiATioxs  OX  nil-:  joixts. 


17') 


convenience,  or  facility  of  execution.^  In  ji^oncral,  (lie  l()iiii:itnilinal 
incision,  by  givinj;  s-n(Iicieiit  exposure  of  the  joint,  iuid  enaijlin<^  the 
operator  to  avoid  easily  the  transverse  division  of 
muscular  attachiiifuts,  ligaments,  and  fibrous  struc- 
tures, should  !)(•  preferred.^  Subperiosteal  exsection 
is  as  follows:  Make  an  incision,  2,  2  (Fig.  143), ^  two 
or  three  inches  long  on  the  posterior  surface  of  the 
joint,  a  little  internal  to  the  middle  of  the  olecranon, 
beginning  about  an  inch  above  the  tip  of  the  olecra- 
non, and  extending  an  inch  and  a  half  or  two  inches 
above  that  point,  upon  the  border  of  the  ulna,  and 
through  muscle,  tendon,  and  periosteum  to  the  bone; 
with  the  elevator,  raise  the  periosteum  of  the  ulna 
towards  the  inner  side,  and  detach  the  inner  half  of 
the  tendon  of  the  triceps  in  connection  with  the  per- 
iosteum, by  means  of  short,  parallel,  longitudinal  in- 
cisions ;  with  the  left  thumb  nail,  draw  the  soft  parts 
which  cover  the  internal  condyle  and  enclose  the  ulnar  Fig.  143. 
nerve  towards  the  epicondyle,  and  detach  them  by  means  of  curved 
incisions  until  the  epicondyle  is  entirely  uncovered;  the  last  incisions 
separate  the  origins  of  the  flexor  muscles  and  the  internal  lateral 
ligament,  their  connections  with  the  periosteum  being  retained;  now 
draw  the  outer  portion  of  the  triccjjs  tendon  outwards  and  separate 
by  short  incisions  from  the  oleci'anon,  maintaining,  however,  its  con- 
nections with  the  periosteum  of  the  outer  side  of  the  ulna,  Avhicli  is 
raised  from  the  bone  with  the  insertions  of  the  anconeus ;  by  repeated 
incisions  along  the  bone,  loosen  the  fibrous  capsule  of  the  joint  from 
the  margin  of  the  humerus,  first  over  the  trochlea,  until  the  internal 
condyle  appears;  detach  the  external  lateral  ligament  and  origins  of 
the  extensor  nniscles,  so  that  all  remain  in  connection  with  each 
other  and  the  periosteum;  now  forcibly  flex  the  arm,  protrude  the 
articular  surfaces  through  the  wound,  and  saw  them  off;  if  the 
ulna  is  sawn  off  below  the  coronoid  process,  separate  the  upper  fas- 
ciculi of  the  brachialis  anticus  without  disturbing  the  union  of  the 
tendon  with  the  i)eriosteum. 

Sub]ieriosteaI  resection  may  ho  so  performed  as  to  retain  the  orii^ins  of  mus- 
cles, as  follows:-*  Jlake  parallel  incisions  over  the  external  and  internal  con- 
dyles, of  pi'oper  leiii^tii  ;  raise  the  soft  parts  from  the  internal  condyle,  separate 
the  attachments  of  the  flexors  with  the  laniellaj  of  bone,  by  means  of  the  chisel; 
raise  the  periostemu  on  both  surfaces  with  the  elevator,  and  divide  the  lateral 
ligament;  repeat  the  same  oiteration  on  the  external  condyle;  now  divide  the 
humerus  above  the  condyles,  separate  tlie  attachments  of  tlie  triceps  with  peri- 
osteum and  lamellaj  of  bone;  detach  the  coronoid  process  from  the  idna;  divide 
the  extremitv  of  the  ulna  and  remove  it. 


1  H.  Culbertson.     ^  Von  Langonbeck;  R.  M.  Hodges. 

4    VoiL't. 


3  Von  Lanarcnbeck. 


176 


OPERATIVE  SURGERY. 


The  J-  incision  1,  1,  1  (Fig.  143)  may  sometimes  be  preferred;  the  arm  being 
semiflexed,  mal^e  an  incision  three  or  four  inches  long  on  the  inner  aspect  of  the 
dorsal  surface  of  the  joint,  commencing  about  two  inches  above  the  internal 
condyle,  and  external  to  the  ulnar  nerve,  which  must  be  carefully  drawn  inside 
when  exposed;  make  a  second  incision  at  right  angles,  dissect  up  the  two  flaps 
to  the  requisite  extent;  remove  the  olecranon  with  strong  cutting  forceps  and 
expose  the  interior  of  the  joint  ;  divide  the  lateral  ligaments;  detach  the  peri- 
osteum from  the  surface  of  the  humerus;  pass  the  handle  of  a  scalpel  under 
the  bone,  and  saw  upon  it;  turn  back  the  fragment  cut  off,  and  detach  it 
from  the  joint;  separate  the  head  of  the  radius  from  the  neighboring  soft 
parts,  pass  a  compress  under  it,  and  cut  it  off,  preserving  all  or  part  of  the 
attachment  of  the  biceps;  then  lay  bare  the  ulna,  prolonging  downwards  the 
internal  incision;  if  necessary,  isolate  the  portion  to  be  cutoff  from  the  peri- 
osteum; put  it  aside  from  the  soft  parts  with  a  compress  or  protecting  guard, 
and  saw  it,  preserving,  if  possible,  the  attachment  of  the  brachialis  anticus. 

If  the  condyles  are  not  diseased  the  hinge  motion  may  be  preserved 
by  operating  as  follows  :  ^  After  the  median  incision  is  made  and  the 
ulna  cleaned,  saw  partly  through  this  bone  about  an  inch  and  a  half 
from  the  olecranon,  and  complete  the  section  with  forceps;  now  dis- 
locate the  humerus  backward  and  saw  oblicpiely  into  the  olecranon 
depression,  first  from  the  bed  of  the  ulnar  nerve,  which  is  drawn  to 
one  side,  and  similarly  from  the  external  condyle;  break  out  the  in- 
cluded mass ;  (Fig. 
144)  divide  the  or- 
bicular and  lateral 
ligaments,  dislocate 
the  forearm  back- 
ward, and  saw  off 
the  radial  extremity. 
The  limb  must  be 
placed  in  a  trough 
splint,  semiflexed  at 
the  elbow,  made  of 
wire  or  tin,  having  a 
large  fenestrum  cut 
out  at  the  joint  to 
admit  of  easy  access 
to  the  wound.  The  gypsum  dressings  may  be  applied  with  steel  or 
iron  bands  curved  at  the  joint  so  as  to  leave  the  wound  perfectly 
free,  and  fastened  above  and  below  in  the  gypsum.  Complete  drain- 
age must  be  secured  by  position  or  drain  tubes,  and  freedom  from 
all  "sources  of  irritation.  As  the  cure  progresses,  passive  motion 
must  be  early  begun  and  persevered  in  until  the  cure  is  complete. 

3.  The   shoulder  joint  consists  of  the  large  and  hemispherical 
bead  of  the  humerus,  opposed  to  the  much  smaller  surface  of  the 
1  H.  J.  Bigelow. 


Fig.  144. 


OPERATIONS  ON  THE  JOINTS.  177 

glenoid  cavity  of  (lie  scapula;  tin;  bones  arc  not  rctaineil  in  position 
by  tbe  direct  tension  of  stronjr  ligaments,  wliicli  would  have  too 
niiicii  restricted  the  movements,  but  by  siirroundiii;,^  mu-cles  and  at- 
mospheric pressure;  the  lii^aments  are  the  capsular,  which  invests  the 
joint,  the  coraeo-humeral,  a  broail  bundle  of  fibres  cxtendinj;  over 
the  upper  and  outer  part  and  attached  to  the  root  of  tlie  coracoid 
process,  and  the  glenoid,  which  surrounds  and  dee[iens  the  articula- 
tion ;  the  function  of  the  joint  is  to  give  support  to  the  arm  and 
great  freedom  of  movement,  which  is  restricted  only  superiorly  and 
posteriorly  by  the  margin  of  the  acromion. ^ 

The  general  mortality  from  excision  is  2(}.84  per  cent,  distributed  according 
to  the  causes  as  follows  :  shot  injuries,  34  ;  injm-ies,  27;  disease,  18.2  The  mor- 
tality of  siiot  injuries,  according  to  the  methods  of  treatment  pursued  is:  ex- 
pectant, 25  percent;  excision,  30;  amputation,  29  percent.^  Various  circum- 
stances intiuence  tiie  mortality,  namely,  the  vigorous  give  10,  and  the  exhausted 
27  per  cent,  of  deaths;  complete  excisions  are  less  fatal  than  partial;  those  in- 
volving a  portion  of  the  head  of  the  humerus  are  not  so  fatal  as  those  involv- 
ing the  entire  head;  excision  of  the  head  and  limited  portions  of  the  scapula 
is  less  fatal  than  removal  of  the  entire  head;  the  mortality  i^:  no  greater  in  the 
removal  of  more  or  less  of  the  upper  fourth  of  the  humerus  than  of  tiie  head 
alone,  and  is  even  less  when  the  upper  fourth  is  removed  with  a  portion  of  the 
scapula,  though  the  mortality  increases  when  the  upper  half  of  the  humerus 
is  removed;  yet  it  is  diminished  to  that  of  excision  of  portions  of  the  head, 
when  a  part  of  the  scapula  is  also  excised;  when  more  than  half  of  the  humerus 
is  excised  the  mortality  is  still  more  diminished.-  The  usefulness  of  the  limb 
after  excision  is  given  as  follows:  After  excision  for  disease,  9.4  per  cent,  had 
perfect  results,  and  70..'>  per  cent,  useful  limbs;  for  injuries,  12. .5  percent,  had 
perfect  results,  and  02.5  usefid  limbs;  for  shot  injuries,  2.7  per  cent,  had  perfect 
results,  and  22.2  per  cent,  useful  limbs.'-  The  amount  of  motion  is  generally 
very  satisfactory,  but  is  not  greater  than  that  after  recovery  with  anchylosis; 
the  arm  cannot  be  elevated  beyond  the  horizontal  line,  and  in  many  cases  hangs 
down  without  any  power  in  the  deltoid;  but  the  movements  of  flexion,  exten- 
sion, an<l  adduction  are  generally  free,  and  there  is  usually  sutficient  power  in 
the  forearm  to  carry  heavy  weights  and  perform  many  of  the  ordinary  domes- 
tic tasks ;  recoverj'  with  anchylosis,  therefore,  gives  as  favorable  results  as 
regards  the  usefulness  of  the  limb  as  the  most  successful  excision. ■• 

The  indications  for  excision  are:  In  caries,  when  a  cure  by  natural 
processes  has  failed  to  follow  judicious  treatment,  either  from  the 
extent  of  the  disease  in  the  bone,  or  the  general  feebleness  of  the 
patient's  powers;  5  in  compound  dislocation;  ®  in  compound  fracture 
with  protrusion  of  the  sliaft  through  the  wounds,  and  rupture  of  the 
capsule  with  destruction  of  the  periosteum;^  in  extensive  shot  in- 
juries, as  the  impaction  of  a  biiU  in  the  head  of  the  humerus,  or 
comminution  of  the  epiphysis.'  Tlie  method  of  operation  has  little 
or  no  influence  upon  the  mortality,  but  it  has  a  marked  relation  to  the 

1  Quain's  Anatomy.         2  h.  Ciilbertson.         »  G.  A.  Otis.        "*  T.  Holmes. 
5  T.  Hryant.  <»  V.  H.  Hamilton.  "  E.  Chassaignac. 

8  G.  A.  Otis;  Von  Langcnbeck. 
12 


178 


OPERATIVE   SURGERY. 


usefulness  of  the  limb,  e.  g.,  the  lonpfitiulinal  incision  gives  8  per 
cent,  perfect,  and  45.6  per  cent,  useful  limbs;  the  various  other  in- 
cisions give  but  a  fraction  over  1  per  cent,  perfect,  and  at  the  high- 
est 11  percent,  useful  linibs.^  The  straight  incision  should,  there- 
fore, be  preferred  in  ordinary  excisions.  Subperiosteal  excision  of 
the  humerus  should,  as  far  as  possible,  be  practiced  in  order  to  secure 
greater  length  of  limb,  for  while  the  degree  of  shortening  ordinarily 
bears  a  certain  relation  to  the  extent  of  bone  excised,  in  subperiosteal 
exsections  this  law  does  not  hold  good,  the  shortening  being  com- 
paratively vastly  less  in  the  latter,  e.  g.,  3.93  inches  removed  with 
periosteum  gave  3  inches  shortening,  while  4  inches  removed,  sub- 
periosteal, gave  only  one-half  an  in(;h  shortening.  ^ 

Exsection  may  be  performed  by  the  methods  given  (pp.  127,  128), 
or  as  follows :  2  Tlie  patient  lying  on  the  back,  the  shoulder  raised 
on  a  cushion,  and  the  external  condyle  looking  forward,  make  an 
incision  commencing  at  the  border  of  the  acromion  near  the  clavicu- 
lar articulation,  and  carry  it  directly  downwards  through  I  he  deltoid 

muscle    to   the  capsule   and 

periosteum  (Fig.  145);  draw 

aside    the    margins    of    the 

wound  with  retractors,  and 

recoL^nize  the  tendon  of  the 

long  head  of  the  biceps;  run 

the  point  of  the  knife  along 

tlie   outside  of   the   tendon, 

opening  the  groove  and  cap- 
sule to  the  acromion ;  draw 

the    tendon    one    side,    and 

while  the  arm  is  rotated  out- 
ward, with  a  circular  sweep 

of  the  knife,  held  perpendic- 
ularly to  the  bone,  divide  the 

capsule  and  the  attachment 

of  the  subscapularis   to   the 

lesser  tuberosity;  then  rotate 

the  arm  inwards,  and  in  the 
same  manner  sever  the  capsule  and  the  insertions  of  the  supra  and 
infra  spinatus  and  teres  minor  from  the  greater  tuberosity;  the  head 
of  the  bone  is  now  thrust  out  of  the  wound  and  removed  by  a  narrow 
back  saw  passed  behind  it.  Any  portion  of  the  glenoid  cavity  may 
be  exsected  through  this  wound.  If  larger  space  is  required,  as  in, 
necrosis  of  the  acromion,  make  additional  incisions  (Fig.  146). 

1  H.  Culbertson.  2  yon  Lan^enbeck. 


Fig.  145. 


Fro.  146. 


OPERATIONS   OX   THE  JOIXTS.  179 

Subperiosteal  resection  may  be  effected  by  this  method  as  follows:  i  divide 
the  periosteum  along  the  incision  and  raise  it  from  the  bone,  first  on  the  inside 
while  the  arm  is  rutateJ  outwards,  detaching  with  it  the  insertions  of  the  sub- 
scapularis;  then  on  the  outside,  while  the  arm  is  rotated  inwards,  separating 
the  insertions  of  the  external  rotators;  this  part  of  the  operation  is  dirticult  in 
primary  resection  owing  to  the  thinness  of  the  periosteum ;  the  head  of  the  bone 
being  now  exposed  it  may  be  turned  out  and  excised. 

ITie  treatment  consists  in  fixing  tlie  afin  upon  the  tfiangular  cush- 
ion'^  antl  inserting  a  suitable  drainage-tube;  in  primary  exsection 
the  tube  may  pass  out  at  an  opening  made  posteriorly,  the  wound 
being  firmly  closed  by  sutures.^ 

JOINTS    OF    THK    LOWER    LIMBS. 

1.  The  phalangeal  joints  should  be  exsected  by  incisions  on  the 
side  of  the  joint,  convex  downwards.  The  treatment  is  the  same  as 
the  similar  operation  in  the  upper  limb. 

2.  The  metacarpo-phalangeal  joints  should  be  excised  by  dor- 
sal inci>ions  along  the  extensor  tendons,  which  must  be  preserved  and 
drawn  aside;  the  treatment  is  extension  and  passive  flexion.  The 
metatarso-phalangeal  joint  of  the  great  toe  may  be  removed  by  a 
lateral  >oini-liiiiar  imision  over  the  j(jint. 

3.  The  metacarpo-tarsal  joints  have  been  exsected  with  good 
results  thus, 3  make  a  semilunar  incision  on  the  dorsum  of  the  foot  and 
dissect  the  flap  upwards  ;  expose  the  first  row  of  tarsal  bones  and 
exsect  their  surfaces  with  a  saw;  now  expose  the  articular  surfaces 
of  the  metacarpal  bones  and  excise  them. 

4.  The  tarsal  joints  generally  become  carious  in  connection  with 
such  extensive  caries  of  the  tarsal  bones  as  necessitates  the  extirpa- 
tion of  entire  bones.  Single  joints  may,  however,  be  excised  when 
the  disease  is  limited,  as  the  astragalo-scaphoid,  the  calcaneo-sca- 
[•boid,  the  calcaneo-astragaloid.  The  incision  should  be  made  over 
the  affected  joint  and  curved,  and  the  artiiular  surfaces  should  be 
removed  with  a  fine  saw  or  gouge. 

.5.  The  ankle  joint  is  a  hinge  joint;  the  inferior  extremities  of 
the  iil)ia  and  lihuia  united  form  a  kind  of  arch  which  embraces  trans- 
versely the  superior  articular  surface  of  the  astragalus  so  as  to  render 
lateral  moven)ents  impossible  when  the  ligaments  are  tense.* 

The  mortality  5  in  the  total  excisions  at  the  ankle-joint  is  12.9  per  cent.,  and 
for  each  class  as  follows:  for  disease,  8.5  per  cent.;  for  injuries,  12.5  per  cent.  ; 
for  shot  injuries,  12. G  jiercent. ;  between  the  ages  of  land  15  there  were  no  deaths; 
the  mortality  was  greatest  in  the  following  order  of  age  periods,  20-25,  15-20, 
2.')-20,  :iO-tO,  50-60,  ami  greatest  from  40-50  years.  In  excision  for  disease 
*the  largest  number  of  deaths  are  found  at  the  period  30-40,  and  in  excision  for 
injuries  the  least  number;  the  cause  of  deatli  attributable  to  the  operation  is 

1  Von  Langenbeck.  2  Fig.  gg.  3  T.  Holmes.  *  Quain's  Anatomy. 

5  H.  Culbertson. 


180  OPERATIVE  SURGERY. 

9.7  per  cent.,  and  to  the  disease  or  injury,  or  other  diseases,  58.8  per  cent.; 
the  mortality  increased  in  proportion  to  tlie  extent  of  bone  excised  as  fol- 
lows :  excision  of  the  tibia  gave  4.7  per  cent. ;  of  the  fibula  8.6  per  cent. ;  of 
the  astragalus,  13  per  cent.;  of  the  tibia  and  fibida  18.4  per  cent.;  of  tiie  tibia, 
fibula,  and  astragalus,  24.4  per  cent. ;  no  deaths  occurred  when  excision  for 
disease  and  injuries  was  not  practiced  until  after  eight  months  from  the  attack, 
from  which  it  is  inferred  that  other  joints  gradiiall}'  became  involved,  rendering 
the  operation  more  and  more  dangerous  by  delay. 

The  usefulness  of  the  limb  was  recorded  as  follows:  in  excision  for  disease,  5  5 
per  cent,  were  perfect,  60.1  per  cent,  useful,  and  in  12  per  cent,  the  extremities 
were  amputated;  for  injuries,  6  per  cent,  were  perfect,  and  59.3  per  cent,  were 
useful,  for  shot  injuries  6  per  cent,  were  perfect,  42  per  cent  useful,  and  6  per 
cent,  were  amputated,  from  which  it  is  concluded  that  a  large  proportion  of  these 
excisions  result  in  more  or  less  usefulness  of  the  limbs. 

The  indications  for  tlie  operation  are  as  follows  :  (o.)  In  compound 
fractures  and  dislocations  of  the  ankle-joint,  with  large,  lacerated 
■wounds,  and  protrusion  of  the  bones,  immediate  excision  greatly  in- 
creases the  chances  of  saving  life  and  limb;^  (bJ)  in  neglected  com- 
pound fractures  at  the  joint,  originally  produced  by  severe  destruc- 
tion, combined  with  extensive  laceration  of  the  ligaments,  attended 
with  suppuration,  formation  of  fistulae,  partial  dislocation,  excision 
is  the  only  remedy  to  produce  rapid  healing,  and  to  gain  a  useful 
limb;^  (c.)  in  acute  suppuration,  due  to  osteo-myelitis,  with  abun- 
dant fetid  discharge,  and  destruction  of  ligaments;  (f/.)  in  cases 
which  have  recovered  with  so  much  deformity  that  the  foot  cannot 
be  made  useful  with  mechanical  appliances  ;  ^  (e.)  in  chronic  caries 
limited  to  the  articulation  of  the  tibia,  fibula,  and  astragalus. ^  The 
indications  against  the  operations  are:  («.)  marked  constitutional 
cachexia;  3  (i.)  chronic  caries  of  the  ankle-joint,  especially  in  chil- 
dren, which  is  curable  by  drainage,  removal  of  carious  portions  of 
bone  with  the  gouge,  and  immobile  a])paratus,*  and  in  persons  ad- 
vanced in  years,  in  whom  amputation  at  the  ankle-joint  is  more 
speedy  and  safe;^  (e.)  extension  of  the  caries  to  the  ankle-joints  and 
bones,  or  upward  along  the  shaft  of  the  tibia.^ 

The  operation  which  best  preserves  vessels,  nerves,  and  tendons, 
as  well  as  the  periosteum,  is  by  two  longitudinal  incisions,  one  over 
the  external  and  the  other  over  the  internal  malleolus,  and  extended 
above  and  below  sufficiently  to  give  free  access  to  all  of  the  diseased 
bone.^  All  transverse  incisions  involving  the  vessels,  nerves,  and 
tendons  should  be  avoided.^ 

Excise  as  follows  i^  The  limb  being  turned  on  the  inner  side  upon  a 
firm  pillow,  make  an  incision  two  or  three  inches  long  on  the  middle 
of  the  fibula  (hnvn  to  tlie  point  of  the  malleolus,  and  sufficiently  deep- 
to  divide  the  periosteum;  from  the  extremity  of  the  malleolus  con- 

1  R.  Volkman.  2  l.  Oilier.  3  T.  Holmes.  ■*  L.  A.  Sayre. 

5  Von  Langenbeck.  6  H.  Hancock. 


OPERATIONS   ON  THE  JOINTS. 


181 


tiniie  the  iixii^ioii  ahoiit  a  third  of  an  incli,  but  inercly  through  the 
skin,  so  as  not  to  injure  the  tendons,  but  to  permit  of  their  being 
raised  from  behind  the  malleohis;  at  the  point  where  tlie  l>one  is  to 
be  divided,  separate  the  periosteum  with  the  raspatoriuin,  and  turn 
down  as  much  as  eircumstanees  will  permit ;  introduce  the  point  of 
the  index  finger,  or  a  spatula,  into  the  interosseous  space  to  jjroteet 
the  soft  parts  during  the  act  of  sawing;  incline  the  saw  slightly  to- 
wards the  joint,  so  that  the  part  to  be  removed  will  be  external  at 
the  point  of  division;  seizing  the  upper  extremity  of  the  fragment 
witli  very  strong  forceps,  separate  its  connections  with  the  raspa- 
torium  and  knife  when  necessary;  now  turn  the  foot  upon  the  ex- 
ternal surface,  and  make  the  same  incision  as  ujjon  the  fibula;  the 
periosteum  is  more  easily  separated  than  from  the  libida;  saw  the 
tibia  in  place  with  a  nne-l)laded  saw,  when  the  parts  are  unyielding 
from  chronic  inflammatory  infiltration  ;  in  recent  injuries,  and  acute 
sui)puralions,  it  may  be  j)ossible,  after  the  periosteum  has  been  sepa- 
rated and  the  liiiaments  incised,  to  gradually  dislocate  the  foot  out- 
wards with  the  aid  of  the  knife,  and  remove  the  tibia  with  the  saw.^ 
To  gain  more  complete  access  in  many  cases,  the  incisions  made 
along  the  centre  of  the  malleoli  may  be  extended  laterally  along  the 
margins  of  the  extremities  of  these  bones,  3  (Fig.  148).     Or,  the 


Fig.  147.  Fig.  148. 

same  result  may  be  attained  by  extending  the  incisions  m.ade  along 
the  posterior  margins  of  the  tibia  and  fibula,  around  tlie  lower  and 
anterior  margins  of  the  malleoli,  3  (Fig.  117).  Remove  the  carious 
parts  of  the  astragalus  with  a  gouge  in  chronic  disease;  resect  only 
traumatic  cases. 

Modilieations  of  the  loiipitiidinal  incisions  are  as  follows  :  Continue  the  ex- 
ternal incision  from  tlie  point  of  the  nialluolus  downwards  and  forwards  to 
within  lialf  an  incli  of  the  base  of  tlie  outer  metatarsal  bone,  making  a  tiap:  re- 
flect this  flap  forward,  expose  and  divide  tlie  flbiila,  and  dissect  out  the  frag- 
ment; now  reverse  llie  foot,  and  continue  in  like  maimer  the  internal  longitu- 
dinal incision  from  the  point  of  the  nnilleoius  to  tlie  projection  of  tlie  inner 
cuneiform  bone;  reflect  the  flap,  divide  the  internal  lateral  ligament  close  to 
the  bone,  and  by  twisting  the  foot  outward  the  tibia  and  astragalus  will  appear 
at  the  wound;  introduce  a  narrow-bladed  saw  between  the  tendons  through  to 
the  external  wound;  saw  off  the  end  of  the  tibia  and  top  of  the  astragalus. ^ 
1  11.  Volkman.  -  II.  Hancock. 


182 


OPERATIVE  SURGERY. 


Fig.  149. 


Fig.  150. 


A  convenient  method  of  suspending  the  Hmb  is  as  follows:^  Make 

a  splint  of  wood  or  metal  fitted  to 
the  anterior  surface  of  the  leg  and 
ankle  (Fig.  149),  with  rings  in- 
serted at  three  points  for  suspension: 
in  its  application,  the  splint  is  well 
padded  and  laid  on  the  front  part 
of  the  leg  and  the  hmb  fixed  by  the 
ordinary  bandage,  the  ankle  being  free  (Fig.  150);  or  the  gypsum 
bandage  may  be  applied  over 
the  splint  and  around  the 
leg,  a  layer  of  old  flannel 
being  first  adapted  to  the 
leg,  and  the  ankle  left  ex- 
posed. 

6.  The  knee-joint  may 
be  regarded  as  consisting  of 
three  articulations  conjoined; 
namely,  that  between  the  patella  and  femur,  and  two  others,  one 
between  each  condyle  of  the  femur  and  the  tibia;  the  ligamentura 
mucosuin  is  an  indication  of  the  original  distinctness  of  the  synovial 
membranes  of  the  inner  and  outer  joint;  the  crucial  ligaments  may 
be  regarded  as  the  external  and  internal  lateral  ligaments  of  those 
two  joints  respectively;  each  portion  of  the  articular  surface  of  the 
femur  belongs  either  to  one  or  other  of  the  three  component  joints  of 
the  knee,  and  no  part  is  common  to  any  two  of  them.^  The  knee 
is  a  hinge-joint,  having  free  motion  in  but  two  directions;  it  is  sup- 
ported principally  by  the  lateral,  the  internal,  and  the  posterior  lig- 
aments, and  in  front  by  the  patella,  and  its  ligamentous  attachments; 
it  has  also  a  capsular  ligament;  the  articular  face  of  the  tibia  has  a 
semilunar  fibro-cartiiage,  which  deepens  the  articular  surface  for  the 
condyles  of  the  femur. 

The  mortality  3  following  excision  is,  for  disease,  in  603  cases,  29.8  per  cent.; 
for  injuries,  in  28  cases,  39.2  per  cent.,  and  for  shot  injurie.«,  in  01  cases,  75  per 
cent.  The  modifying  conditions  are  as  follows:  the  age  most  favorable  for  excis- 
ion is  for  disease  and  injuries,  5-10;  for  shot  injuries,  15-20;  the  period  of  the 
disease  most  favorahle,  is  3-6  months,  and  the  most  unfavorable  15-18  months, 
for  shot  and  other  injuries,  secondary  operations  are  most  favorable;  traumatic 
influences  greatly  increase  the  mortality  in  excisions  for  disease;  complete  ex- 
cisions for  disease  give  a  higher  per  cent,  of  mortality  (29)  than  partial  (25),  but 
for  shot  injuries  it  is  the  same  (75);  in  general  the  mortalitv  increases  in  propor- 
tion as  less  than  2|  inches  are  removed;  from2|  to  4  inches  the  mortalityis  least; 
above  4  inches  it  reaches  its  highest  rate;  removal  of  the  patella  increases  the 
mortality  from  2.34  percent.,  not  removed,  to  27.3  per  cent.;  in  excision  for 
disease  the  greatest  per  cent,  died  from  the  operation  (37),  a  less  per  cent,  from 
1  R.  Volkmau.  2  Quain's  Anatomy.  3  H.  Culbertson. 


OPERATIONS   ON  THE  JOINTS.  183 

other  diseases  (28.0),  and  the  least  per  cent,  from  tlie  orif;inal  disease  (20.2);  in 
excision  for  siiot  injuries  an  etjual  number  die  from  tiie  injury  and  the  operation  ; 
in  excision  for  shot  injuries  tiie  mortality  is  mainly  attril)utal)le  to  the  character 
of  the  injuries  sustained,  42.2  percent.,  and  to  the  supervention  of  other  diseases, 
15.5  per  cent.,  the  deaths  traceable  to  the  operation  being  l)ut  4.4  per  cent.  It 
is  noticeable  that  exsectioiis  at  the  knee-joint  for  disease  are  becoming  more 
and  more  succes.^ful;  for  example,  before  18.50  the  mortality  was  o'.iAH  jier  cent.; 
1850-60  it  was  30.73  per  cent.;  1800-70  it  was  21.0;  1870-4,  10.9  per  cent. 

The  usefulness  of  the  limb  is  thus  recorded:  In  excisions  for  disease  in  420 
cases,  14.3  per  cent,  were  perfect,  42.4  per  cent,  were  useful,  4.0  per  cent,  not 
useful,  and  17.8  were  amputated;  for  injuries,  in  17  cases,  17.6  percent,  were 
perfect,  04.7  per  cent,  were  useful,  and  11  7  per  cent,  were  amputated;  for  shot 
injuries,  in  17  cases,  58.8  per  cent,  were  useful,  and  23.5  per  cent,  amputated; 
in  46  cases  of  e.xcision  for  deformity,  19.5  per  cent,  had  perfect,  and  07.8  per 
cent,  had  useful  limbs;  the  amount  of  bone  lemoved  varied  from  |  an  inch  to 
over  4  inches,  but  the  usefulness  did  not  depend  upon  the  extent  removed; 
the  removal  of  the  patella  secures  a  greater  degree  of  usefulness  than  its  re- 
tention ill  the  proportion  of  76.9  per  cent,  of  the  former  to  31.4  per  cent,  of  the 
latter. 

From  these  facts  it  would  appear  that  this  e.xcision  gives  a  large  percentage 
of  useful  liLubs;  but  those  who  believe  that  the  value  of  the  limb  depends  upon 
a  permanently  firm,  unyielding,  osseous  union  of  the  femur  and  tibia,  will 
conclude  that  the  recorded  results  must  be  taken  with  some  allowance,  for  too 
often  the  union  proves  to  be  librous  and  has  been  followed  by  amputation, ^ 
or  the  limb  bends  under  constant  use,  or  bows  outward  or  inwards,  or  disease 
recurs.-  15ut  great  progress  has  recently  been  made  in  perfecting  excision  at 
this  joint,  and  limited  motion  is  no  longer  regarded  as  impairing  its  function. 3 
The  results  that  have  followed  the  efforts  that  have  been  made  to  preserve  the 
natural  relations  of  the  librous  structures  and  muscles,'*  give  gratifying  j)roofs 
that  the  knee-joint  will  be  no  exception  to  the  rule  that  excision  should,  as 
far  as  practicable,  restore  the  functions  of  joints. 

Present  experience  indicates  that  excision  should  b.-  had  recourse 
to  only  in  those  cases  where  the  disease  begins  to  endanger  life, 
where  hectic  fever  has  set  in,  the  patient  loses  flesh,  the  existence 
of  an  intra-articular  suppuration  luaiiifests  itself,  and  a  long-con- 
tinued rational  treatment  has  failed;^  the  number  of  fistulaj  or  ab- 
scesses in  the  neighborhood  of  the  joint  is  of  little  importance  in 
deciding  the  question,  as  they  may  exist  without  grave  implication 
of  the  joint  itself,  and  atonic  caries  may  exist  with  cheesy-like 
matter,  in  the  joint,  and  destruction  of  ligaments,  with  little  dis- 
cliarge.^ 

On  the  other  hand,  as  a  general  rule,  excision  is  not  indicated, 
(1)  when  the  patient  is  under  five  or  over  foriy-five  years  of  age; 
for  in  the  first  case  there  is  a  possibility  of  recovery  without  an 
operation,  and  a  risk  that  excision  would  check  the  growth  of  the 
limb,  and  in  the  second  case,  the  advantage  of  excision  over  amputa- 
tion is  not  stifBcient,  in  the  most  favorable  cases,  to  balance  the  in- 
1  R.  Volkmau.  2  X.  Holmes.  8  (j.  Iliiter.  ■•  Von  Langenbeck. 


184  OPERATIVE  SURGERY. 

creased  risk;^  (2)  when  the  disease  is  of  recent  origin,  or  limited  to 
the  synovial  membrane,  as  in  simple  hydrarthrosis,  however  lonw  it 
may  have  continue  1,  for  a  natural  cure  may  still  often  be  obtained 
by  position,  rest,  extension,  and  constitutional  and  local  treatment;  ^ 
(3)  when  there  is  satisfactory  evidence  of  the  presence  of  organic  vis- 
ceral disease,  as  phthisis;  (4)  when  there  is  caries  of  the  articular 
ends  of  the  bones  in  a  healthy  patient,  for  the  disease  may  often  be 
brought  to  a  successful  termination  by  incision  and  the  removal  of  the 
dead  bone,^  and  the  passage  of  setons  of  oakum  or  perforated  rubber 
tubing  through  the  joint  to  secure  complete  drainage  and  the  escape 
of  carious  particles;*  (5)  when  the  disease  has  lasted  many  years 
and  the  process  of  natural  cure  is  well  advanced,  for  by  placing  the 
part  in  proper  position,  securing  rest  and  aiding  the  natural  efforts, 
recovery  with  anchylosis  may  be  obtained  ;  ^  (6)  when  shot  injuries 
involve  the  joint,  for  if  not  severe,  expectant  treatment  will  give  the 
best  results,  but  if  severe,  amputation  of  the  thigh  should  be  per- 
formed ;  even  in  traumatic  suppurations  in  consequence  of  pene- 
trating wounds  or  severe  contusions,  well-managed,  conservative 
treatment,  with  the  plaster  of  Paris  bandage,  ice,  incisions  at  the 
proper  time,  injections  of  concentrated  nitrate  of  silver,  extension  if 
necessary,  will  save  more  patients  than  secondary  excision.^ 

The  following  suggestions  as  to  the  extent  of  the  excision  are  im- 
portant: The  patella  should  not  be  removed,  unless  diseased,  as  the 
preceding  facts  show  a  large  per  centage  of  recoveries  when  it  is  .un- 
disturbed; it  is  also  essential  to  the  formation  of  a  firm,  well  applied 
flap;  ^  if  carious,  the  diseased  part  may  be  removed  with  the  gouge 
or  forceps;  in  excision  of  the  knee-joint  in  children,  remove  at  first 
a  thin  slice  of  bone,  and,  in  case  this  should  not  suffice,  with  the 
gouge  scrape  out  carefully  the  softened  and  brokon-down  osseous  tis- 
sue, leaving  the  much  thinned  cortical  substance  with  the  periosteum, 
behind;  the  epiphyseal  cartilage  is  often  by  this  means  laid  entirely 
bare  from  the  side  of  the  joint;  if  perforated  with  fistulous  openings 
a  small  spoon  must  be  introduced  and  every  particle  of  diseased  tissue 
removed  ;  in  very  young  children  it  will  often  even  not  be  necessary 
to  remove  any  part  of  the  tibia  with  the  saw,  it  being  practicable  to 
remove  the  diseased  part  with  the  spoon;  if  the  epiphyseal  cartilage 
can  be  saved  only  in  part,  no  more  should  be  sacrificed  than  is 
actually  necessary.^ 

Tiie  method  of  operation  will  depend  upon  the  kind  of  joint  sought 
to  be  ol)tained;  if  union  of  the  excised  bones  is  necessary,  the  U- 
sha[)ed  infi>ion  is  in  general  preferable  to  others,  as  it  permits  the 
removal  of  any  necessary  amount  of  bone  without  injuring  the  soft 

'  T.  Ilolnit's;  J.  Asluubt,  Jr.         -  J.  A^l^l^st,  Jr.  3  T.  Bryant. 

4  L.  A.  Sayre.  5  j.  Ashurst,  Jr.;  T.  Bryant,      o  It.  Volkman. 


OPERATIONS   ON  THE  JOINTS. 


185 


^J 


parts,  and  both  corni-rs  of  the  wouml  are  situated  as  low  as  the  ana- 
tomical conditions  will  allow. ^  If  an  attempt  is  made  to  retain  mo- 
tion, a  lateral  incision  ^  is  to  be  preferred,  which  admits  of  oxsection 
with  the  least  destruction  of  the  ligamentous  tissues  of  the  joint.  In 
exsectioM  designed  to  secure  union,  the  articular  surfaces  should  be 
so  divided  as  to  give  a  forward  angle  at 
the  point  of  union;  this  is  secured  by  saw- 
ing the  bones  in  the  lines  h,  k,  and  /,  j 
(Fig.  151);  the  amount  of  bone  removed 
must  of  course  depend  upon  the  extent  of 
the  disease. 

Exsect  as  follows: ^  The  leg  being 
slightly  flexed  on  the  thigh,  make  a  curved  •' 
incision,  commencing  at  the  insertion  of  the 
internal  lateral  ligament  into  the  inner  con- 
dyle of  the  fvmur,  and  passing  just  below  h 
the  lower  extremity  of  the  patella,  terminate  ' 
it  at  the  same  point  on  the  external  aspect 
of  the  joint;  the  lateral  inci.-ions  should 
not  be  made  lower  than  the  insertion  of 
the  lateral  ligaments,  to  avoid  division  of 
the  articular  arteries;  carefully  remove  all 
diseased  and  degenerated  tissues  ;  reflect 
this  flap  upwards 
(Fig.  152);  re- 
move the  patella, 
if  diseased,  if 
not,  leave  it  un- 
disturbed and  divide  the  lateral  and  in- 
terarticular  ligaments;  pass  a  fold  of  cloth 
through  the  joint,  and  draw  it  firmly  under 
the  extremity  of  the  bone  to  be  sawn,  thus 
completely  isolating  the  soft  parts  behind; 
apply  the  saw  first  to  the  extremity  of  the 
femur,  and  then  to  the  articular  head  of 
the  tibia;  cleanse  the  wound,  and  wire  the 
bones  together. 

The   wire    selected    should    be    the    an- 
nealed iron-wire,  and  it  shouhl  be  inserted 
Fig.  152.  at  two  points  corresponding  to  the  inser- 

tion of  the  lateral  ligaments. 

Subperiosteal   resection,  with   lateral  curved   incision,  is  made  as  follows  :2 


Fig.  151. 


1  R.  Volkniaii. 


2  Vou  Langeubeck. 


8  J.  K.  Wuou. 


186 


OPERATIVE  SURGERY. 


Fig.  163. 


2,  2  (Fig.  15-3)  Extend  the  knee  and  make  a  curved  incision  five  to  six  inches 
long  on  the  inner  side,  beginning  two  inches  above  the  patella,  at  the  inner  bor- 
der of  the  rectus  fenioris  muscle,  its  convexity  looking  back- 
wards, passing  over  the  posterior  edge  of  the  internal  con- 
(\y\e  and  ending  on  the  inner  side  of  the  crest  of  the  tibia,  two 
or  three  inches  below  the  patella.  In  the  upper  part  of  the 
wound  is  the  vastus  internus,  beneath  which  the  tendon  of 
the  adductor  niaginis  presents  itself;  in  the  lower  portion  the 
tendon  of  the  sartorius  muscle  is  seen;  these  tendons  must 
not  be  injured;  cut  through  the  internal  lateral  ligament  in 
the  line  of  the  joint;  separate  the  internal  insertion  of  the 
capsule  from  the  anterior  surface  of  the  internal  condyle  as 
high  as  the  vastus  internus :  detach  the  internal  alar  liga- 
ment from  the  anterior  border  of  the  tibia  to  the  middle 
line;  flex  the  knee,  and,  as  it  is  again  slowly  extended,  by 
a  powerful  effort  luxate  the  patella  outwards;  divide  the  cni- 
cial  ligaments,  and  to  separate  the  posterior  crucial  ligament 
from  the  spine  of  the  tibia  rotate  the  internal  condyle  of  the 
tibia  forwards;  divide  the  external  lateral  ligament  together 
with  the  adjoining  portion  of  the  capsule,  by  a  free  cres- 
cent-shaped incision,  carried  several  lines  below  the  tip  of 
the  external  epicondyle  ;  the  joint  now  gaps  widely  ;  cut 
the  posterior  wall  of  the  capsule;  push  the  articular  heads  of  the  femur  and 
tibia  successively  forward,  and  saw  them  off;  if  it  is  necessary  to  remove  the 
patella,  cut  around  it  wiih  the  knife  at  the  border  of  its  cartilaginous  surface, 
and  then,  by  means  of  the  periosteal  knife,  peel  it  out  of  its  peri<)>teum,  so  that 
the  latter  continues  in  connection  with  the  ligamentum  patella;  and  the  extensor 
tendons.  Before  the  wound  is  closed,  a  strong  drainage-tube  is  inserted,  and 
allowed  to  protrude  at  the  most  depending  part.  It  is  also  useful  to  make  a 
counter-opening  out  of  which  the  other  end  of  the  drainage-tube  is  allowed  to 
hang,  as  also  one  through  the  upper  attachment  of  the  capsule  of  the  joint. 

ih^;  after-treatment  is  generally  very  prolonged  and  tedious,  for 
the  average  time  in  excision  for  disease  in  recovered  cases  is  one  hun- 
dred and  seventy-eight  da3'S,  and  in  fatal  cases  fifty-eight  days.  The 
conditions  to  be  seciu'ed  and  maintained,  of  the  greatest  importance 
for  success,  are,  (1)  proper  coaptation  of  the  cut  surfaces,  and 
(2)  complete  immobility  of  the  parts.  These  conditions  are  secured 
by  apparatus  which  fixes  the  limb  immovably,  and  yet  leaves  the 
excised  purts  so  exposed  that  dressings  may  be  renewed  without 
disturbance  of  the  bones.  The  gypsum  splint  and  bandage,  when 
judiciously  applied,  give  the  most  satisfactory  results.  Of  several 
forms  the  following  meets  all  the  indications  most  perfectly;  ^  provide 
a  compress  by  folding  a  strip  of  firm  cloth,  or  lint,  extending  from 
just  below  the  tuber  i.schii  nearly  to  the  heel,  twelve  times  together, 
and  of  such  width  as  not  to  touch  the  angles  of  the  incision;  dip  it 
in  a  solution  of  plaster  of  Paris,  and  apply  it  to  the  posterior  sur- 
face; retain  it  by  <2y})sum  bandages,  so  applied  as  to  leave  the  front 
part  of  the  knee  uncovered;  an  iron  brace  may  be  added  over  the 
1  P.  H.  Watson;  F.  Esmarch. 


OPERATIONS   ON   THE  JOINTS. 


187 


knee  for  strength.  ^  Or,  make  a  wooden  concave  splint  to  the  calf 
of  the  leg  and  back  of  the  thigh,  but  naiTow  at  the  knee;  also  an 
iron  rod  for  suspin<;ion,  apply  the  dressing  thus:  Pad  the  posterior 
splint  with  lint  or  cotton-wool,  and  cover  that  part  corresponding 
to  the  site  of  the  wound  with  gutta-percha  cloth,  or  hot  paraffine; 
I>Iace  the  liuib  in  poj^itiun  and  carefully  adjust  it;  place  the  iron 
rod  on  the  front  and  lay 
folded  lint  between  it  and 
the  limb  at  the  groin,  at 
the  u[)per  part  of  the 
tibia,  and  at  the  bend 
of  the  ankle;  apply  an 
open  woven  roller  bandage 
around  the  whole  dressing 
from    the    toes    upwards  F"^-  ^5^- 

excei)t  at  the  site  of  the  wound  ;  over  this  apply  the  gypsum  band- 
age in  two  or  three  layers  ;  when  the  dressing  is  firm,  suspend  the 
limb  by  the  hook;  the  wounds  may  now  be  dressed  without  disturb- 
ing the  part. 

6.  The  hip-joint  is  a  large  ball-and-socket  joint,  in  which  the 
globular  head  nf  the  femur  is  received  into  the  acetabulum  or  coty- 
loid cavity  of  the  innominate  bone;  tlie  articulating  surface  of  the 
acetabulum  is  formed  by  a  broad,  ribbon-shaped  cartilage  occupying 
the  upper  and  outer  part,  and  folded  round  a  depression  which,  ex- 
tending from  the  notch,  is  hollowed  out  in  the  bottom  of  the  cavity, 
and  is  occupied  by  delicate  adipose  tissue  covered  with  synovial  mem- 
brane ;  the  articulating  surface  of  the  femur  presents  a  little  beneath 
its  centre  a  pit  in  which  the  round  ligament  is  attached;  movement 
is  allowed  in  every  diiection,  extension  being  limited  by  the  anterior 
fibres  of  the  capsular  ligament,  and  flexion  by  the  contact  of  the 
neck  of  the  femur  with  the  acetabulum. ^ 

The  results  of  excision  are  as  follows:  For  shot  injuries  the  mortality  is  89 
per  cent,  in  a  total  of  121  cases;  at  the  different  periods  it  is  as  follows :  pri- 
mary, .36.7  per  cent;  iiiterinetliate,  48.1  percent.;  secondary,  15.2  per  cent.,* 
giviiit;  a  larj^e  preponderance  iu  favor  of  tlie  secondary  operation.  For  disease, 
the  mortality  is  45  per  cent,  in  a  total  of  426  cases;  the  most  favorable  age  is 
1  to  10  years;  the  most  favorable  period  is  when  the  disease  has  existed  12  to  15 
months;  the  <;enera!  mortality  is  greater  in  complete  than  in  partial  excisions. 
There  is  but  little  difference  in  the  mortality  when  the  head  and  neck,  or  the 
head,  neck,  trochanters,  or  the  head,  trochanters,  and  upper  part  of  the  shaft  are 
removed,  provided  the  amount  of  pelvic  bone  excised  is  limited;  the  mortality 
centre  is  the  head  of  the  femur,  the  rate  diminishing  as  the  bone  is  removed 
outwards  to  the  shaft  and  increasing  as  it  advances  upwards  upon  the  pelvis.' 
The  usefulness  of  the  limb  after  excision  for  disease  is  equivalent  to  93.8  per 
cent,  of   the  recovered  cases;   complete  excision   gives  a   better  result  in  re- 

1  R.  Volkman.  2  Quain's  Anatomy.  3  H.  Culbertson. 


188  OPERATIVE  SURGERY. 

covered  eases  than  partial,  the  former  having  45.8  per  cent,  and  the  latter  35.8 
per  cent,  perfect  limbs,  and  the  former  having  48.6  per  cent,  and  the  latter  56.6 
useful  limbs;  after  excision  for  shot  injuries  3.9  more  or  less  useful  limbs  and 
5  imperfectly'  useful  limbs  are  recorded  in  119  cases. i 

The  indications  for  exsection  are  as  follows:  In  compound  disloca- 
tions ^  in  shot  injuries  when  the  head  is  shattered  by  the  ball,  or  the 
ball  is  impacted  in  the  head  ;  ^  in  disease,  when  suppuration  and  dis- 
oro-anization  of  the  textures  of  the  joint  continue  unrelieved  hy  or- 
dinary treatment,  and  the  patient's  health  is  in  fair  condition.* 
Superficial  or  limited  acetabular  disease  does  not  interfere  with  the 
performance  and  good  results  of  excision  of  the  head  of  the  femur ; 
even  when  the  acetabulum  is  much  involved,  or  pelvic  suppuration  ex- 
ists, it  is  important  to  afford  a  free  escape  to  the  pus  by  the  removal 
of  the  head,  neck,  and  great  trochanter  of  the  femur.^  It  should 
not  be  attempted  in  cases  in  which  abscesses  form  with  little  or  no 
fever,  the  nutrition  of  the  patient  remaining  satisfactory;  nor  when 
anchylosis  is  complete,  though  free  suppuration  is  present. ^  In  gen- 
eral, the  following  conditions  should  guide  in  deciding  to  exsect  for 
disease:  (1)  in  chronic  coxitis  with  formation  of  abscesses  and  fistu- 
lous openings,  the  suppuration  being  abundant,  with  lever  at  night, 
and  progressive  weakness  ;  (2)  when  an  acute  suppurating  coxitis, 
with  high  increase  of  temperature,  supervenes  upon  a  chronic  one  in 
which  dry  granulations  without  suppuration  have  filled  the  acetabu- 
lum ;  (3)  when  an  iliac  abscess  which  is  forming  shows  that  pus  has 
perforated  the  acetabulum  and  entered  the  pelvic  cavity;  (4)  when 
during  suppuration,  the  head  of  the  femur  has  separated  and  left  the 
acetabulum.^ 

The  period  of  operating  should  be  primary  in  compound  disloca- 
tions and  shot  fractures.  In  disease  it  has  not  yet  been  accurately 
decided  what  is  the  earliest  stage  of  its  course  in  which,  the  opera- 
tion is  justifiable,  but  the  evidence  strongly  corroborates  the  opinion 
that  usually  it  is  delayed  too  long.^  The  surgeon  cannot  commit  a 
greater  error  than  by  delaying  excision  too  long  in  severe  cases,  and 
operating  only  when  the  patient  is  excessively  debilitated.^  Though 
the  mortality  would  seem  to  diminish  in  proportion  as  the  shaft  is 
removed,  yet  there  can  be  no  doul)t  that,  as  a  rule,  the  extent  of  the 
incision  should  depend  upon  the  amount  of  disease ;  if  limited  to  the 
head,  that  part  alone  should  be  removed ;  ^  if  the  neck  is  carious,  the 
trochanter  may  still  be  preserved ;  but  if  the  latter  is  involved,  the 
bone  must  be  divided  at  the  trochanter  minor. 

The  methods  of  operation  are  numerous,  but  the  single  incision 
along  the  axis  of  the  trochanter,  with  subperiosteal  removal  of  the 

1  H.  Culbertson.  2  p.  H.  Hamilton.  3  r.  Volkman. 

■•  L.  A.  Sayre;  T.  Annandale ;  L.  Verneuil;  C.  Hiiter.  5  T.  Annandale. 

6  Von  Langenbeck  ;  Sheede ;    C.  Hiiter. 


OPERATIONS   OX   THE  JOINTS. 


189 


bone,  most  marly  mei-ts  the  anatomical  indication  of  the  part.  Of 
the  several  arteiics  distributed  to  this  region,  namely,  the  gluteal, 
sciatic,  obturator,  external  and  internal  circumflex,  and  the  superior 
perforating  i)y  anastomosis,  the  only  one  which  approaches  the  line 
of  this  incision  near  enough  to  be  incised  before  dividing  into 
branches  of  distrllnition  too  small  to  give  rise  to  noticeable  hiemor- 
rhage,  is  a  twig  of  the  internal  circumflex,  which,  at  one  eighth  to 
one  fourth  of  an  inch  from  the  insertion  of  the  obturator  externus, 
breaks  up  into  its  terminal  divisions  ;  this  branch  may  be  avoided  by 
keeping  the  point  of  the  knife  well  against  the  bone,  and  dividing 
the  tendon  of  the  obturator  externus  muscle  in  the  digital  fossa.^ 

Exsect  as  follows  ^ ;  (Fig.  155)  The  pa- 
tient lying  on  the  sound  side,  with  a  strong 
knife  commence  an  incision,  1,  1  (Fig.  155), 
at  a  point  midway  between  the  anterior  in- 
ferior spinous  process  of  the  ilium  and  the 
top  of  the  great  trochanter;  carry  it  in  a 
curved  line  over  the  ilium,  in  contact  with 
the  bone,  across  to  the  top  of  the  great  tro- 
cbanter;  extend  it  not  directly  over  the  cen- 
tre of  the  trochanter,  but  midway  between 
the  centre  and  its  posterior  border;  com- 
plete it  by  carrying  the  knife  forward  and 
inward,  making  the  whole  length  of  the  in- 
cision four  to  six  or  eight  inches,  according 
to  the  size  of  the  thigh;  if  the  periosteum 
has  not  been  divided  by  the  first  incision, 
carry  the  point  of  the  knife  along  the  same 
line  a  second  or  third  time;  an  assistant  sep- 
arating the  wound  with  the  fingers  or  retract- 
ors, the  great  trochanter  (Fig.  157),  is 
exposed ;  with  a  narrow  thick  knife  make  a  second  incision  through 
the  periosteum  only  at  right  angles  with  the  first  at  a  point  an  inch  or 
an  inch  and  a  half  l)clow  the  top  of  the  great  trochanter,  opposite  or 
a  little  above  the  lesser  trochanter,  and  extend  it  as  far  as  possible 
around  the  bone,  making  sure  that  the  periosteum  is  freely  divided;  at 
the  junction  of  the  two  incisions  of  the  periosteum  introduce  the  blade 
of  the  periosteal  elevator,  and  gradually  peel  up  the  periosteum  from 
either  side  with  its  fibrous  attachments  until  the  digital  fossa  has  been 
reached;  with  the  point  of  the  knife  applied  to  the  bone  divide  the 
attachments  of  the  rotator  muscle,  and  continue  to  elevate  the  peri- 
osteiun,  carefully  avoiding  rupturing  it  at  any  point;  when  the  perios- 
teum is  removed  as  far  as  necessary,  adduct  the  limb  slightly,  de- 
1  J.  A.  Wyeth.  2  l.  A.  Sayre. 


Fig.  155. 


190 


OPERATIVE  SURGERY. 


Fig.  156. 


press  the  lower  end  of  the  femur  sufficient    to    allow   the    head   of 

bone  to  be  lifted  out  only  so  far 
as  is  requisite  to  permit  its  re- 
moval with  the  taw  g  :  divide  the 
bone  just  above  the  trochanter 
minor,  and  remove  the  fmgment; 
if  the  head  of  the  bone  cannot 
be  raised  before  division  on  ac- 
count of  the  involucrum,  saw  the 
bone  first  and  then  remove  the 
head ;  if  the  shaft  at  the  point 
of  section  is  necrosed,  expose  and 
exsect  more;  examine  the  acetab- 
ulum and  if  found  diseased  re- 
move all  dead  bone;  if  perforated, 
the  internal  periosteum  will  be 
found  peeled  off,  making  a  kind 
of  cavity  behind  the  acetabulum, 
and  all  diseased  bone  must  be 
very  carefully  chipped  off  down 
to  the  point  where  the  periosteum 
is  reflected  from  sound  bone;  all 
sinuses  must  be  thoroughly  cleaned  of  particles  of  bone  and  false 
meiubrane  ;  cleanse  the  wound  thoroughly,  fill  it  with  Peruvian  bal- 
sam, and  stuff  it  with  oakum,  always  avoiding  cotton  or  lint,  and 
close  only  the  extremities  with  stitches.^ 

Or,  make  an  incision  2,  2  (Fig.  155), 2  commencing  about  three  inches  below 

the  crest  of  the  ilium,  and  the  same  distance 
posterior  to  the  anterior  superior  spine, 
downwards  to  the  trochanter  major,  and 
then  along  the  centre  of  the  shaft  of  the 
bone. 

An  exploratorj'  incision  may  be  made  by 
entering  the  knife  immediately  above  and 
in  a  line  with  the  posterior  margin  of  the 
great  trochanter,  and  making  an  incision 
sutficiently  long  and  deep  to  allow  the  finger 
to  explore  the  joint;  extension  of  this  in- 
cision upward  or  downward  two  inches  will 
admit  of  excision  of  the  head  of  the  feniur.^ 
The  following  method  *  is  approved : 
Make  a  longitudinal  incision  over  the  great 
trochanter  2^  to  4  inches  in  length,  in  a  line 
Fro.  157.  with  the  axis  of  the  femur,  and  directed  to 

the  posterior  superior  spine  of  the  iliac  bone;  two  thirds  of  the  incision  is  made 
in  the  glutei  muscles  above  the  trochanter,  and  one  third  on  the  trochanter; 
1  L.  A.  Savre.  ^  l.  Oilier.  3  X.  Annandale.  ^  Von  Langenbeck. 


OPERATIONS  ON  THE  JOISTS. 


191 


separate  the  muscles  down  lo  tlie  neck  of  the  femur,  in  the  direction  of  the 
longitudinal  incision  until  the  neck  of  the  femur  and  the  margin  of  the  ace- 
tahulum  are  entirely  free;  incise  the  capsule  in  a  longitudinal  direction,  and 
notch  it  slightly  on  both  sides  at  the  margins  of  the  acetabulum;  while  the  fin- 
ger is  passed  into  the  wound,  cause  rotation  of  the  femur,  which  enables  the 
operator  to  separate  all  the  muscular  attachments  on  either  side  of  the  incision; 
the  head  may  be  di.-located  and  sawn  off,  or  the  bone  may  be  divided  in  place 
and  the  fragment  removed  (Kig-  157). 

The  operation  ^  by  a  horizontal  incision  at  the  front  part  of  the  joint  has  been 
advised;  the  incision  commences  external  to  the  crural  nerve,  and  involves  the 
sarlorius,  rectus,  and  tensor  vaginsc  femoris  muscles.  It  is  not  well  ada|)ted  for 
real  e.\cision  of  the  joint,  as  it  admits  only  of  an  operation  on  the  neck  of  tlie 
femur,  unless  the  incision  is  very  large;  as  the  wound  is  in  front  of  the  joint  it 
does  not  favor  free  discharge  of  matter;  the  incision  is,  however,  well  adapted 
for  simply  dilating  tistubv;  situated  in  front  of  the  joint,  or  for  gouging  out  the 
joint  by  means  of  sharp  spoons,  or  for  the  extraction  of  the  head  of  the  femur 
when  separated. - 

The  after  trtatmont  requires  fjreat  care  and  unwearied  patience; 
in   order   that  the  exeised    joint  may 
be  kept  at   rest,   the  wound   must  be 
so  placed  and  exposed  that  the  dress- 
in;^  and  cleansinj;  may  be  accomplished 
without  moving  the  part ;  daring  the 
first  weeks  it  is  necessary  to  keep  the 
acetabulum  and  the  surface  of  the  fe- 
mur well  apart,  and  the  soft  parts  well     j/ 
stretched,  as  in  excision  of  the  elbow,    \\ 
shoulder,  and  the  ankle-joints;  by  this 
means    healthy    granulations   make   a    |i^ 
more   rapid    progress,  and   the   pelvis 
ami  femur  come  into  close  contact  by 
the  contraction  of  the  granulations  and 
their  formation  into  cicatricial  tissue. - 
The  wire  cuirass  is  the  best  apparatus 
to    meet    these   indications,  especially 
when  the  patient  is  a  child  (Fig.  158). 

Apply  it  as  follows  :  The  cuirass  being 
properly  padded,  place  the  patient  in  it  so 
that  the  anus  is  opposite  the  opening  and 
free  from  any  obstruction;  dress  the  well  leg 
as  follows:  make  it  perfectly  straight,  tlu-u 
screw  up  the  foot-rest  until  it  is  brought 
firmly  against  the  heel;  place  a  pad  between 
the  rest  and  the  foot  to  absorb  perspiration; 
cover  the  instep  with  cotton  or  blanket,  and 

carrj'  a  roller  (irmly  rotmd  it  and  the  foot-  Fig.  158. ^ 

rest,  and  thence  up  over  the  limb;  before  applying  it,  place  a  piece  of  paste- 
board, leather,  or  several  folds  of  paper,  over  the  leg,  knee,  and  thigh  to  pre- 

1  Kozer.  2  R.  Volkmaii.  8  C.  II.  &  Co.;  W.  F.  Ford. 


192 


OPERATIVE  SURGERY. 


vent  the  slightest  bending  of  the  knee;  carry  the  roller  around  the  perineum, 
and  over  tlie  outer  arm  of  the  instrument,  and  several  times  back  through 
the  perineum,  and  then  across  the  pelvis,  by  which  means  the  well  limb  is  made 
a  firm  counter-extending  force;  dress  the  operated  leg  as  follows:  apply  two 
strips  of  adhesive  plaster,  two  to  four  inches  in  width,  according  to  the  size  of 
the  leg,  one  upon  either  side,  extending  above  to  the  sinuses,  and  below  suffi- 
ciently to  admit  of  their  attachment  to  the  foot-rest  where  extension  is  made; 
screw  up  the  foot-rest  to  meet  the  heel,  and  bring  down  the  ends  of  the  plaster 
and  fasten  them  securely  around  it;  then  extend  the  foot-rest  slowly  and  grad- 
ually by  means  of  the  screw,  until  the  limb  is  brought  down  to  its  full  extent; 
if,  by  long  contraction,  the  adductors  and  tensor  vaginaB  femoris  do  not  yield, 
divide  their  tendons  and  fascitB  subcutaneously;  now  apply  a  bandage  from  the 
toes  over  the  entire  limb  to  the  wound;  place  a  mass  of  oakum  aroiuid  the 
wound  to  absorb  the  discharge,  and  continue  the  roller  firmly  over  it  to  the  body; 
this  dressing  will  probably  not  require  to  be  changed  for  from  forty-eight  to 
sixty  hours,  or  until  the  dressings  are  moistened  with  the  discharges,  when  the 
oakum  must  be  removed,  the  wound  cleansed  with  carbolic  solution,  and  again 
filled  with  Peruvian  balsam,  and  dressed  as  before;  after  this,  change  the  dress- 
ings once  or  twice  daily  according  to  the  discharge,  and  remove  the  patient  from 
the  entire  instrument  as  often  as  may  be  necessary;  the  well  leg  should  be 
removed  at  least  once  a  week,  and  free  movement  given  to  all  the  joints;  the 
cuirass  should  be  used  for  a  month  or  two,  when  a  long  or  short  hip  splint 
may  be  substituted,  and  the  patient  allowed  to  exercise. i 

111  the  absence  of  tliis  apparatus,  the  limb  may  be  placed  in  ex- 
tension, supported  by  sand-bags  or  pillows,  ^  or  it  maybe  encased 
in  piaster  of  Paris,  with  suitable  openings  for  the  discharges. 

The  gypsum  bandage  is  best  adapted  to  adults,  and  is  most  ser- 
viceable when  applied  with  a  strip  of  iron  spanning  the  joint,  and 

maintaining  the  thigh 
and  pelvic  portions  in 
position  (Fig.  159);^ 
this  stirrup  of  steel 
may  be  movable  by 
means  of  a  bracket, 
making  extension  j)os- 
sible ;  its  construction 
and  application  are 
apparent.  With  chil- 
dren, extension  by  the 
application  of  weights 
and  projjcr  positions  of 
the  limb  are  the  best 
means ;  the  patient 
Fig-  159.  uiay   be    placed    on   a 

divided  mattress,  of  which  the  two  different  parts,  exactly  corre- 
sponding to  the  spot  where  the  excision  was  made,  are  separated  by 
an  interstice  of  several  inches.^ 
1  L.  A.  Sayre.         2  t.  Annandale.  3  c.  F.  Stillman-  *  R.  Volkman. 


III. 

THE    MUSCULAR    SYSTEM. 

THE   MUSCLES;    THE   TENDONS;    THE   FASCIiE; 
THE  BURS.E. 


CHAPTER  XVIII. 

INJURIES   OF  THE   MUSCULAR   SYSTEM,   AND  SPECIAL 
OPERATIONS. 

I.    MUSCLES. 

1.  Ruptures  of  muscles  may  be  partial  or  complete.  The  former 
are  sprains,  and  occur  in  severe  wrenches  of  the  limbs  or  back; 
they  are  restored  l)y  rest  and  soothing  applications,  and  when  the 
soreness  is  relieved,  by  gentle  movements,  massage  and  galvanism. 
A  muscle  may  be  com[)letely  ruptured  subcutaneously  when  the 
whole  force  is  thrown  in  a  violent  and  unexpected  manner  upon 
one  or  two  muscles,  or  in  violent  paroxysms  of  muscular  spasms,  as 
in  tetanus  ;  the  point  of  separation  is  commonly  at  the  junction  of 
the  muscle  with  the  tendon  ;  the  accident  is  attended  with  extreme 
pain,  resembling  that  occasioned  by  a  smart  blow  from  a  stick,  and 
often  by  a  distinct  sound  like  the  snapping  of  a  cord;  all  motion  of 
the  part  is  either  impossible,  or  is  accompanied  by  such  severe  pain, 
with  spasmodic  twitching,  as  to  cause  the  patient  to  desist;  deep  in- 
dentations are  found  at  the  seat  of  rupture  by  retraction  of  the  di- 
videil  ends,  and  often  considerable  swellings;  there  is  always  extrav- 
asation of  blood  with  discoloration  of  the  skin.  Simple  subcuta- 
neous ru[>tures  of  muscles  are  not  serious  injuries.^  Place  the  part  in 
a  position  most  favorable  for  relaxing  the  muscles,  and  bringing  the 
surfaces  in  apposition,  and  support  it  with  splints  and  other  appli- 
ances; maintain  the  extremitiL's  of  the  separated  nuiscle  in  contact 
by  evenly  applied  flannel  bandages  or  laced  belts,  aided  in   some 

1  T.  Billroth. 
13 


194  OPERATIVE   SURGERY. 

cases  by  a  strip  of  leather  or  gutta  percha.  At  first  there  is  a  con- 
nective tissue  interinediate  substance  whicli  soon  undergoes  such 
shortening  and  atrophy  tliat  a  firm  tendinous  cicatrix  forms  ;  func- 
tional disturbances  rarely  remain  of  any  considerable  amount,  though 
there  may  be  some  weakness  of  the  extremity  and  loss  of  delicate 
nioveuient.^  If  the  rupture  involve  the  skin  also,  the  injury  is  grave 
in  proportion  to  the  extent  of  the  laceration;  if  the  muscle  protrudes 
at  the  wound,  it  must  not  be  cut  away  but  reduced  to  position;  if 
necessary,  enlarge  the  wound  of  the  skin,  and  after  replacement  close 
the  wound  with  antiseptic  dressing  and  treat  it  with  a  view  to  secure 
union  without  suppuration. 

2.  Incised  wounds  cf  muscles  are  followed  by  i-etraction  of  the 
cut  ends.  There  is  always  observed  a  peculiar  inversion,  subsid- 
ence, or  tucking  in  of  the  muscular  fibres  at  the  divided  parts,  so 
that  nearly  all  the  fasciculi  direct  their  cut  ends  towards  the  subja- 
cent bone  or  fascia;  in  repair,  new  muscular  fibres  are  never  formed, 
but  the  retracted  portions  become  inclosed  in  a  tough,  fibrous  bond 
of  union;  in  some  cases  the  cut  ends  of  the  muscle  are  imperfectly 
united,  but  the  action  of  the  muscle  is  not  lost,  for  one  or  both  of  its 
ends,  acquiring  new  attachments  to  the  subjacent  parts,  still  act, 
though  with  diminished  range.-  Whether  the  wound  is  open  or  sub- 
cutaneous, approximate  the  cut  extremities  of  the  muscle  as  perfectly 
as  possible  both  by  position  and  dressings,  and  retain  them  in  this 
condition  by  absolute  rest;  if  the  wound  is  open,  employ  deep  su- 
tures to  muscles  and  skin,  with  bandages  above  and  below  fastened 
over  the  wound  so  as  to  give  uniform  sujiport  and  prevent  separa- 
tion. 

II.    TEXDOXS. 

1.  Rupture  of  a  tendon  is  caused  by  a  sudden  action  of  its  mus- 
cles, as  of  the  tendo-Achillis  in  springing  upon  the  toes;  or  violence 
from  accidents,  as  in  dislocations;  the  tendon  yields  more  frequently 
than  the  nniscle,  the  point  of  separation  being  at  the  junction  of  the 
tendon  to  the  muscle,  or  at  the  attachment  to  the  bone  ;  the  itipture 
occurs  with  a  snap  and  a  shock  as  if  the  part  had  received  a  sharp 
blow,  with  sudden  and  comp'ete  loss  of  function.  In  treatment,  the 
divided  ends  must  be  as  accurately  approximated  as  possible,  and 
retained  until  firm  union  is  established;  though  close  adaptation  can 
not  be  hoped  for,  yet  a  perfect  union,  with  recovery  of  the  action  of 
the  muscle,  usually  takes  place,  for  the  severed  ends  are  brought 
closer  and  closer  together  by  the  contraction  of  the  new  material  as 
it  becomes  perfected,  and  the  remaining  deficiency  is  fully  compen- 
sated by  the  accommodating  nature  of  the  muscle.  The  appliances 
1  T.  Billroth.  2  gjr  j.  Paget. 


INJURIES   OF   THE  MUSCULAR  SYSTEM.         195 

in  the  troattiiunt  of  ruptured   muscles   ami   tendons   are   I  lie  same, 
'i'lie  following  muscles  and  tendons  are  more  frecjuentlv  ruj)tured  :  — 

(n.)  The  triceps  extensor  cubiti  usually  rui)tures  at  tlie  insertion  into  the 
olecranon;  bamlaj;!'  tliL-  aim  from  aliove  dowiiwanls,  with  a  splint  in  front  to 
keep  it  extended;  or  apply  adhesive  strips  over  the  body  of  the  museles,  and 
allowiiif^  them  to  eross  over  the  ohcranon,  make  firm  traction  and  fasten  tlie 
ends  over  the  splint  (»n  the  anterior  surface. 

{b.)  The  biceps  flexor  cubiti  is  liable  to  have  the  tendon  of  its  long  head 
rupturetl,  the  other  usually  ruptures  at  a  later  date;i  bandage  the  arm  up- 
wards, and  lix  the  limb  with  the  hand  upon  the  opposite  shoulder;  union  rarely 
occurs. 

(c. )  The  quadriceps  extensor  cruris  may  be  ruptured  near  the  patella; 
place  the  limb  on  a  straight  splint,  the  foot  elevated;  fix  the  patella  with  ad- 
liesive  strips  so  that  it  cannot  descend  ;  ai>ply  adhesive  strips  over  the  eiUire 
compound  nuiscle,  each  commencing  at  the  upper  limits  of  the  thigh;  but  all 
converging  to  the  i>atella  ;  to  the  combined  strips  united,  attach  a  rope  passing 
over  a  pulley,  and  add  a  weight  sul^ieient  to  maintain  the  parts  in  apposition. 

((/.)  The  tendo-Achillis  may  riijiture,  or  be  detached  from  its  insertion  into 
the  OS  caleis;  inunediately  ajiply  a  bandage  to  the  leg  from  above  downwards, 
over  the  calf,  but  stop  short  of  the  point  of  separation,  lest  the  tendon  be  forced 
down  to  the  bone  and  form  attachments.  Extend  the  foot  on  the  leg,  fliex  the 
leg  on  the  thigh,  and  fix  the  parts  in  this  position  by  attaching  a  belt  placed 
above  the  knee  to  the  heel  of  a  stout  slipper  on  the  foot,  if  detached  from  its 
insertion. 

2.  Incised  -wounds  of  tendons  are  followed  by  contraction  of 
the  muscle  or  the  (iisplacement  of  the  attached  part.  They  are  rec- 
ognized by  loss  of  function,  and  the  depression  at  the  point  of  separa- 
tion. This  is  one  of  the  few  structures  of  the  body  capable  of  com- 
plete reproduction,  and  the  extent  of  the  new  part  varies  within 
given  limits,  according  to  the  separation  of  the  cut  tendon.'^  The 
obstacles  to  perfect  union  of  tendon  are  :  failure  to  maintain  the 
parts  in  apposition,  too  early  use  of  the  limb,  division  in  dense 
fibrous  sheaths,  the  extremities  becoming  adherent  to  the  inner  sur- 
face of  the  sheath.  Place  ami  niaint;iin  the  limb  in  such  position  as 
to  secure  easy  apposition  of  the  cut  extremities  ;  if  the  wound  is 
open,  first  unite  the  cut  extremities  of  the  tendon  by  suture,  as  car- 
bolized  catgut,  and  then  close  the  external  wound;  avoid  putting 
the  tendon  on  the  stretch  for  several  weeks. 

III.    BURS^. 

Wounds  of  bursa?  are  liable  to  lead  to  inflammation  and  suppura- 
tion; and  secondarily,  involve  the  neighboring  joints.  Cleanse  and 
disinfect  the  wound,  and  endeavor  to  secure  immediate  union  ;  if  pus 
form,  open  the  abscess  under  carbolized  spray,  and  apply  antiseptic 
dressings. 

1  T.  Brvant.  2  w.  Adams. 


196  OPERATIVE  SURGERY. 


CHAPTER   XIX. 

DISEASES   OF   THE   MUSCULAR   SYSTEM   AND   SPECIAL 
OPERATIONS. 

L    MUSCLES. 

1.  Inflammation  of  muscles,  myositis,  is  rarely  an  idiopathic  dis- 
ease ;  it  may  occur,  however,  in  the  tongue,  psoas,  pectoral,  and 
gluteal  muscles,  and  in  those  of  the  thigh  and  calf  of  the  leg;  the 
acute  form  usually  terminates  in  abscess,  although  resolution  has 
been  observed.^  After  an  injury,  the  symptoms  usually  appear  sev- 
eral weeks  later,  and  result  from  some  lack  of  repair  in  the  injured 
part,  due  to  the  want  of  the  necessary  rest  which  an  injured  muscle 
so  much  requires  in  the  process  of  healing.  ^  It  begins  with  parenchy- 
matous swelling  of  the  muscular  fibres,  and  passes  raj)idly  into  sup- 
puration and  abscess;  the  bellies  of  entire  muscles,  as  the  psoas,  may 
be  converted  into  pus;  but  more  commonly  the  abscess  is  limited  to 
a  spot  varying  in  size  from  a  pea  to  a  walnut,  according  to  the  cause 
in  each  particular  case ;  the  most  trifling  inflammation  affecting  the 
striped  muscles  of  the  trunk  and  limbs  occasions  the  most  violent  dis- 
turbance of  function;  the  muscle  rests  in  a  state  of  contraction,  and 
any  attempt  to  extend  it  is  most  strenuously  opposed  by  the  patient 
on  account  of  the  intense  pain  to  which  it  gives  rise.^  In  large  ab- 
scesses which  are  compressed  by  strong  fasciae  there  is  contraction 
of  the  muscles  in  the  substance  of  which  the  abscess  develops,  as  in 
psoitis;  but  in  small  and  not  very  painful  abscesses,  and  in  traum;)tic 
inflammations  of  the  muscles,  there  is  usually  no  contraction.^  Reso- 
lution of  the  inflammation  should  be  attempted  by  rest  and  the  ap- 
plication of  ice-bags.  When  pus  forms,  warm  moist  applications 
must  be  made,  and  as  soon  as  abscess  is  detected  it  should  be  opened, 
and  with  antiseptic  dressings  if  a  large  muscle  is  involved. 

II.    TENDONS. 

1.  Inflammation  of  tendons,  and  their  sheaths,  is  liable  to  follow 
sprains,  or  other  injuries.  The  sheaths  may  inflame,  with  exudation 
of  fibrinous  serum,  which  often  induces  temporary  or  permanent  ad- 
hesions of  the  sheath  to  the  tendon;  or  suppuration  may  occur  with 
necrosis  of  the  tendons;  there  is  now  fever  beginning  with  a  chill; 
if  the  inflammation  and  suppuration  extend,  the  fever  becomes  con- 
tinued and  remittent  in  form ;  if  intermittent  chills  occur,  there  is 
great  danger.  Inflammation  of  the  sheaths,  arising  from  unknown 
1  T.  Billroth.  2  T.  Bryant.  3  e.  Rindfleisch. 


DISEASES  OF  THE  MUSCULAR  SYSTEM.         197 

causes,  begins  as  an  acute  phleo;mon,  the  cellular  tissue  participates, 
and  the  limb  swells  greatly.  The  symptoms  at  the  first  are  pain  on 
motion,  and  slight  swelling;  sometimes  a  friction  sound  is  present, 
or  grating  in  the  sheath  perceptible  to  the  ear  or  hand.  Resolution 
may  occur  without  suppuration,  the  limb  remaining  stiff  a  long  time, 
as  the  adhesions  between  the  sheath  and  tendon  do  not  break  down 
until  after  months  of  use;  if  e.xtcnsive  suppuration  follow,  the  ten- 
dons usually  become  necrosed  and  escape  from  the  abscesses  as  white 
threads  or  shreds,  followed  by  permanent  stiffness  of  the  fingers. 
The  treatment  of  slight  inflammation  of  the  tendons,  with  crepitation, 
is  rest  on  a  splint  and  local  application  of  tincture  of  iodine,  or  add 
a  blister.^  If  the  symptoms  are  more  severe,  elevate  the  limb  and 
apply  ice ;  if  this  is  painful,  use  hot  fomentations  over  a  lar^^e  sur- 
face;  if  the  inflammation  extend,  with  throbbing,  and  hardness, 
make  a  free  ii^cision  along  the  centre  of  the  sheath,  to  relieve  the 
tensely  strangi-lated  tissues,  even  though  no  pus  is  present. "-^  If  pus 
is  detected,  make  numerous  openings,  and  secure  free  drainage  from 
position  or  tubes;  if  the  disease  still  progresses,  and  the  patient 
sinks,  amputation  of  limb  may  be  necessary  to  save  life.^  In  the 
more  chronic  states,  where  abscesses  burrow,  though  free  openinofg 
have  been  made,  resort  to  pressure  with  pads  of  lint  soaked  in  liquor 
plumbi  acetat.,  and  combine  tonics  and  good  diet.- 

The  synovial  sheaths  suffering  chronic  inflammation  mav  be- 
come distended  with  a  fluid,  jelly-like  and  containing  white  bodies. 
The  sheaths  in  the  hand  are  most  frequently  affected;  there  is  a 
gradual  formation  of  a  swelling  in  the  hollow  of  the  hand  and  the 
lower  end  of  the  volar  side  of  the  forearm,  and  the  fluid  mav  be  felt 
passing  in  the  sheath  to  the  forearm  under  the  ligament  of  the  wrist; 
the  fingers  are  generally  flexed  and  cannot  be  fullv  extended;  the 
movements  of  the  hand  and  fingers  are  somewhat  limited,  but  there 
is  no  pain;  the  fluid  is  jelly-like,  with  white  bodies.  In  other  cases 
there  is  a  partial  hernia  of  the  sheath,  with  dropsy,  a  gan<rlion  forming 
a  kind  of  sac-like  protrusion  about  the  size  of  a  pigeon's  e£jg,  and 
fdled  with  synovia;  it  appears  most  commonly  on  the  dorsal  surface 
of  the  wrist,  in  connection  with  the  extensor  tendons;  it  also  contains 
thick  mucus,  and  white  bodies,  like  melon  seeds.^  In  treatment 
avoid  any  operation  which  mi'j:ht  cause  suppuration.  In  dropsv  of 
the  sheath,  open  the  sheath  antiseptically,  usini;  the  sprav  continu- 
ally until  the  carbolized  dressiuiis  are  fully  applied,  ami  insert  a 
long  tube  for  drainage.  If  the  antiseptic  method  cannot  be  applied, 
avoid  operating  as  long  as  possiljle,  and  then  proceed  cautiouslv,  as 
follows:  Open  the  sheath  either  by  incision  or  puncture,  and  inject 
iodine  ;  if  puncture  is  made,  select  a  medium-sized  trocar  which  will 
1  T.  Billroth.  2  J.  L.  Clarke. 


198  OPERATIVE  SURGERY. 

allow  the  escape  of  the  fibrinous  bodies;  inject  tepid  water  through 
the  canula  to  force  out  these  bodies;  when  all  has  been  removed,  in- 
ject slowly  a  syringe  full  of  a  mixture  of  equal  parts  of  tr.  iodine  and 
water,  or  add  an  equal  quantity  of  iodide  of  potassium;  remove  the 
canula,  cover  the  wound  with  a  small  compress,  bind  up  the  hand 
and  forearm  carefully  and  place  it  on  a  splint;  if  the  tension  subse- 
quently becomes  severe,  remove  the  dressings,  close  the  puncture 
with  plaster  and  paint  with  iodine.^  In  the  case  of  ganglia,  attempt 
rupture  with  the  thumbs  pressed  firmly  upon  it;  failing,  open  it  anti- 
septically,  or  by  subcutaneous  free  incisions  of  the  sac,  and  evacua- 
tion of  its  contents  into  the  connective  tissue;  the  limb  should  be 
kept  at  perfect  rest  during  the  treatment. 

III.    BURS.E. 

BurssE  are  deep-seated  or  subcutaneous  sacs  to  prevent  friction ; 
the  former  are  interposed  between  a  muscle  or  its  tendon  and  a 
bone  or  the  exterior  of  a  joint,  or  between  two  muscles  or  tendons, 
and  frequently  communicate  with  the  cavities  of  joints  ;  the  latter 
lie  immediately  under  the  skin,  interposed  between  it  and  some  firm 
prominence  underneath.'^  From  their  location  and  function,  they 
are  peculiarly  liable  to  injury,  hence  to  inflammation. 

Infiammatioii  of  the  deep-seated  burste  appears  as  local  painful 
swellings,  which  are  often  mistaken  for  common  phlegmons.  The  in- 
flammation may  resolve  with  more  or  less  consolidation,  or  terminate  in 
suppuration,  or  assume  a  chronic  form  with  an  accumulation  of  fluid, 
—  dropsy.  The  early  treatment  should  be  rest  and  cold  ;  if  pus  form, 
they  must  be  opened  cautiously  with  antiseptics,  and  healed  as  quickly 
as  possible;  if  they  become  dropsical,  use  blisters,  tincture  iodine, 
and  pressure,  and  open  them  for  radical  treatment  only  when  obsti- 
nate, and  then  with  antiseptics.  Tlie  bursas,  which  occasionally  en- 
large, are  numerous  in  the  region  of  large  joints,  as  the  hij^,  the  knee, 
the  shoulder,  and  elbow  ;  the  following  are  examples  :  — 

(a.)  The  deltoid  bursa  '  at  times  communicates  with  tlie  joint  through  the 
bicipital  groove;  when  inflamed  there  is  swelling  around  tlie  shoulder  joint, 
pain  and  crepitation  on  movement,  simulating  mischief  in  the  joint;  it  may 
become  distended  with  simple  fluid,  or  loose  bodies;  tlie  treatment  should  be 
absohite  rest  of  the  arm  and  blisters;  it  should  be  opened  only  after  grave  con- 
sideration, and  when  obstinate,  and  there  is  bulging  in  front  of  the  deltoid.  If 
antiseptics  are  used  there  is  much  less  danger. 

{b.)  The  quadriceps  extensor  cubiti  bursa"  often  inflames  and  the  swell- 
ing is  distinguished  from  that  of  the  knee  b}'  being  limited  to  the  upper  border- 
of  the  patella,  especially  noticeable  when  the  patient  stands,  and  fluctuation  is 
above  and  not  through  the  joint.  The  treatment  is  rest,  tr.  iodine,  blisters,  and 
when  very  obstinate,  tapping;  if  it  suppurate  it  must  be  freely  opened,  but  with 
anti*eptics. 

1  T.  Billroth.  2  Quaiu's  Anatomy.  3  T.  Bryant. 


DISEASES   OF   THE   MUSCULAR  SYSTEM.         199 

(c.)  The  ligamentum  patella  bursa,  distended  t)y  lliiid.  presents  itself 
conspicuously  on  both  sides  of  the  ligamentum,  extending  from  the  tul)ercle  to 
the  top  of  the  tibiii;  it  is  painful  after  exercise,  swollen,  and  tender;  the  treat- 
ment is  rest,  blisters,  and  tr.  iodine;  as  it  often  communicates  with  the  joint, 
operations,  as  incision,  puncture,  the  insertion  of  a  seton,  are  very  dangerous. 

C)llier  bursiv  which  are  liable  to  intlamc,  and  which  must  be  treated  on  the  same 
principles,  are  located  as  follows:  Under  the  tendon  of  the  subscapularis;  in  the 
sheath  of  the  longhead  of  the  biceps  ;  between  the  tendon  of  the  latissimus 
dorsi  and  the  inferior  angle  of  the  scapula;  under  the  insertions  of  the  tendon 
of  the  biceps  into  the  radius;  under  the  tendon  of  the  triceps;  several  at  the 
hip,  the  largest  beneath  the  conjoined  tendon  of  the  psoas  and  iliacus  internus; 
several  in  the  popliteal  space;  under  the  insertion  of  the  tendo-Achillis;  about 
the  ankle  and  tarsal  articulations. 

Of  the  siipcrficiiil  huvsie  those  on  the  patella  and  olecranon  are 
types;  if  the  iiilhimmation  is  acute  the  lUiid  collects  rapiilly,  the 
skin  is  red,  the  swelling  painful,  preventing  walking;  the  fluid  may 
wholly  or  partially  be  absorbed,  or  the  sac  may  suppurate,  or  rup- 
ture subciitaneou.^ly.  or  through  the  skin.  The  treatment  of  the  acute 
stage  is  rest,  with  cold;  and  in  the  chronic  stage  rest,  with  tr.  iodine, 
compression,  blisters,  mercurial  ointment,  or  i)lasters.  Compression  ^ 
by  means  of  a  well-padded  splint  in  the  ham,  and  bandaged  as  firmly 
as  possible  with  a  flannel  roller,  often  effects  a  cure.  But  chronic 
drop.sy  of  this,  as  of  other  bursae,  is  not  always  curable  by  these  rem- 
edies; more  radical  measures  are  required,  as  injection  of  iodine, 
free  incision,  or  extirpation;  injections  are  not  dangerous  if  the  pa- 
tient remains  quiet;  use  equal  ])arts  of  strong  tr.  iodine  and  water; 
first  draw  off  a  portion  of  the  fluid,  then  inject  the  preparation,  re- 
tain it  for  several  minutes,  and  withdraw  whatever  will  reenter  the 
syringe.  If  the  sac  is  very  thick,  it  is  justifiable  to  extirpate  it  en- 
tirely, which  must  be  done  with  great  care  to  avoid  injtu'ing  the  cap- 
sule of  the  joint. '^  After  the  walls  are  reached,  if  the  edge  of  the 
knife  is  directed  towards  the  tumor,  it  may  be  dissected  from  the  ex- 
panded tendon  of  the  quadriceps,  and  from  the  ])atella,  without 
injury  to  eiiher;  remove  any  redundancy  of  integument;  bring  the 
edges  of  the  flap  exactly  together;  fix  the  limb  upon  a  well-fitting 
posterior  splint,  and  secure  it  by  a  few  turns  of  a  roller  inclosing  the 
front  of  the  knee  and  portions  of  the  limb  above  and  below.'  Still 
greater  safety  is  secured  by  operating  and  dressing  with  antiseptics 
and  confining  the  limb  in  a  fenestrated  gypsum  bandage. 


III.    COXTII.\CTION. 

Although  contraction  can  only  take  place  in  muscles,  yet  a  wider 
meaning  is  generally  given  to  the  term,  and  tendons  and  fascia  may 

1  R.  Volkman.  ^  T.  Billroth.  3  p.  H.  Hamilton. 


200 


0  PER  A  TI VE  S  UR  GER  Y 


become  contracted,  being  shortened  and  shrunken,  and  without  their 
normal  elasticity. ^ 

1.  A  muscle  contracts  when  inflamed,  and  where  there  is  inflam- 
matory new  formation  in  muscle,  cicatricial  connective  tissue  may  take 
the  place  of  the  muscle;  this  process  causes  the  drawing  together 
by  atrophy  and  induces  contraction.  Contractions  may  also  result 
from  continued  direct  irritation  of  certain  nerves,  or  they  may  have 
a  reflex  origin,  or  follow  as  a  result  of  long-continued  paralysis  of 
antagonizing  muscles.  Finally,  shortening  may  occur  as  a  result  of 
continued  approximation  of  the  points  of  insertion,  as  in  curvatures 
of  the  spine,  and  clubfoot;  this  form  of  contraction,  contraetured 
muscle, '-^  is  an  adaptation  of  the  muscle  to  the  new  relations  of  the 
points  of  origin  and  insertion,  and  is  attended  with  diminished  func- 
tion, and  consequently  size,  adaptive  atrophy.^  The  treatment  de- 
pends upon  the  cause;  during  inflammation  extension  should  be 
maintained  to  avoid  contraction,  but  if  contraction  finally  occurs, 
deformity  must  be  relieved  by  division  of  the  muscle;*  in  paralysis  of 
antagonizing  muscles,  as  in  infantile  paralysis,  contraction  must  be 
prevented  by  well-adjusted  appliances;  if  contraction  exist  and  has 
so  long  continued  that  the  muscle  has  become  adapted  to  its  new 
position, 3  it  must  be  divided  before  the  deformity  can  be  overcome. 

2.  A  tendon  undergoes  contraction,  both  as  a  result  of  inflamma- 
tion and  from  long  continued  position, 
and  not  only  causes  deformities,  but  ag- 
gravates and  renders  permanent  exist- 
ing deformities.  The  treatment  is  the 
same  as  in  contraction  of  muscles. 

3.  The  fasciae  may  shrink  from  the 
displacement  of  a  part  by  which  the  fas- 
cia is  relaxed,  as  occurs  in  the  fascia 
lata  during  hip- joint  disease,  or  the  con- 
traction may  occur  as  a  result  of  a  low 
grade  of  inflammation,  especially  in  the 
palmar  fascia.  This  contraction,  though 
sometimes  occurring  in  persons  suffering 
from  rheumatism,  seems  to  be  due  to 
frequently  repeated  and  protracted  pres- 
sure of  hard  substances,  as  in  handling 
tools.  The  integument  and  subjacent 
fascia  inflame,  induration  succeeds,  and 
adhesion  with  contraction  follows,  with  flexion  of  the  finger  to  which 
the  fascia  is  attached  (Fig.  160),  at  first  slight,  but  progressively  in- 
creasing until  in  some  cases  the  ends  of  the  fingers  are  almost  in 
1  T.  Billroth.  -  A.  Delpech.  8  sjr  j.  Paget.  4  e.  Brown-Sequard. 


Fig.  IGO. 


DISEASES   OF   THE  MUSCULAR   SYSTEM.         201 

contact  with  the  palm  of  the  hand.  This  morbid  condition  may  oc- 
cur in  one  or  in  botli  hands  ;  the  fingers  are  not  usually  all  contracted 
to  the  same  degree ;  the  ring  finger  is  generally  more  flexed  than  the 
others,  and  the  little  finger  more  than  the  index  or  middle  fin<'er. 
There  is  little  or  no  pain,  except  an  effort  is  made  to  extend  the 
finger,  when  great  res^istauce  is  offered  and  severe  pain  is  induced; 
indurated  and  knotty  cords  can  be  seen  and  felt,  extending  from  the 
palm  to  the  fingers,  the  firmness  of  which  is  greatly  increased  by 
efforts  at  extension;  these  curds  are  formed  by  contracted  bands  of 
the  palmar  fascia  together  with  the  closely  adherent  intcirument; 
the  skin  of  the  palm  is  drawn  into  folds  in  the  form  of  arcs  of  cir- 
cles whose  concavities  are  downwards  towards  the  fingers;  in  some 
cases  the  sheath  of  the  flexor  tendon  is  involved  in  the  vicinity  of  a 
single  articulation,  generally  that  of  the  first  with  the  second  pha- 
lanx. It  is  distinguished  from  paralysis  of  extensors  by  complete 
extension  of  fingers;  from  cicatrices  by  the  absence  of  scar;  from 
rheumatism  by  the  healthy  state  of  the  joints;  from  contraction  of 
flexor  muscles  and  tendons  by  the  absence  of  tension  when  there 
is  extreme  flexion  of  wrist.  The  case  always  progresses  unfavorably 
when  untreated,  but  recovery  is  probable  if  the  contracted  bands 
are  thoroughly  divided,  and  the  affected  fingers  are  extended  and 
maintained  in  that  j)Osition  by  projjer  splints,  and  passive  mution  is 
vigorously  and  persistently  applied.  As  the  treatment  is  tedious  and 
painfid,  and  must  be  protracted  through  several  months,  the  patient 
should  be  fully  informed  of  these  facts.  Secure  full  anicsthesia; 
make  subcutaneous  section  as  far  as  practicable  at  every  point  where 
there  is  tension;  if  the  skin  is  very  adherent  divide  it,  but  as  slightly 
as  possible;  close  the  wounds  with  adhesive  plaster  and  place  the 
fingers  in  an  exten<led  position  ;  apply  to  the  back  of  the  forearm, 
band,  and  affected  finirers,  a  metallic  splint  adapted  to  the  surface, 
with  an  interveniiiii  layer  of  lint  or  cotton  wool;  secure  the  fingers 
to  the  corresjiomling  portions  of  the  splint  by  narrow  strips  of  ad- 
hesive plaster,  and  the  arm,  by  a  bandage;  renew  the  dressings  at 
intervals  of  two  or  three  days,  and  apply  passive  motion  persistently 
until  recovery  is  coinplcted.^ 

The  fascia  lata  is  liable  to  undergo  permanent  contraction  bv  lon<' 
continued  spasmodic  action  of  the  tensor  va'jinai  femoris-,  as  in  hip- 
joint  disease.  Division  of  the  muscle  will  not  alwavs  be  followed  bv 
sufficient  relaxation  of  the  fascia;  wherever  contractions  still  exist, 
section  must  be  made  with  the  long  tenotome  carried  under  the 
bands. 

1  W.  G.  Elliott;  A.  C.  Post. 


202  OPERATIVE  SURGERY. 

CHAPTER  XX. 

GENERAL   OPERATIONS   ON   THE   MUSCULAR   SYSTEM. 

I.     MYOTOMY;  TENOTOMY;  FASCTATO.MY. 

These  several  general  operations  on  the  musoular  system,  namely, 
mvotomy,  section  of  muscle;  tenotomy,  section  of  tendon;  and  fas- 
ciatomy,  section  of  fascia,  are  generally  classed  under  the  more  com- 
mon term,  tenotomy.  They  are  undertaken  for  the  relief  of  deformi- 
ties or  displacement  of  parts,  caused  or  maintained  by  the  contraction 
of  muscle,  tendon,  or  fascia,  or  of  all  combined.  The  muscle  and  its 
tendon  are  more  frequently  alone  at  fault,  but  occasionally  the  fascia 
is  also  involved  in  the  contraction.  The  true  value  of  tenotomy  does 
not  consist  simply  in  division  of  the  contracted  structures,  but  rather 
in  substituting  for  the  unyielding  tissue  a  cicatrix  capable  of  being 
extended,  and  which  will  enable  the  part  to  perform  again  its  projjer 
function.  It  follows  that  to  render  the  opei'ation  successful,  great 
discrimination  is  required  in  the  selection  of  the  muscle  to  be  divided 
and  the  point  of  division,  and  in  the  after  treatment.  In  general 
the  operator  may  select  between  division  of  the  muscle  and  tendon, 
and  then  preference  should  always  be  given  to  the  tendon,  owing  to 
the  marked  difference  in  the  methods  of  repair  of  these  two  tissues, 
namely,  in  section  of  muscle  repair  is  always  by  fibrous  tissue,  while 
tendon  and  fascia  are  regenerated.  If  the  tendon  has  a  synovial 
sheath  avoid  it  if  practicable,^  or  if  divided,  precautions  should  be 
taken  to  prevent  inflammation  by  the  use  of  a  tenotome  rendered 
aseptic  by  immersion  in  a  carbolized  solution. 

1.  The  indications  favorable  to  tenotomy  depend  upon  the  follow- 
ing conditions:  (1)  The  contracted  tissues  must  have  undergone  such 
adaptive  changes  as  to  render  extension  by  mechanical  means  im- 
possible or  unadvisable;  (2)  the  antagonizing  muscles  should  not 
be  so  paralyzed  that  they  are  not  capable  of  restoration  of  function, 
at  least  in  some  degree.  To  determine  these  questions  the  following 
general  rides  are  useful,  and  should  be  fully  applied  in  every  case:  — 
{a.)  The  force  of  the  contraction  may  be  tested  as  follows  :2  If  the 
displaced  limb  can  be  brought  nearly  into  position  by  the  force  of  the 
h;inds,  the  contraction  is  not  so  great  and  permanent  that  mechani- 
cal appliances  will  not  overcome  the  distortion;  but  if  manual  efforts 
do  not  greatly  improve  the  abnormal  position  of  the  part,  a  condition 
exists  which  i*enders  extension  excessively  tedious,  or  quite  impossi- 
ble, {b.)  The  permanency  of  the  contraction  is  proved  thus:^  Place 
1  T.  liiUrotli.  2  w.  Adams.  3  L.  A.  Sayre. 


OPERATIONS  OX  THE  MUSCULAR  SYSTEM.     20.3 

the  part  contraL-tt'il  as  marly  as  possible  in  its  normal  position  by 
means  of  manual  tension  srraduaily  ai)plit'(l,  and  tlien  carefully  re- 
tain it  in  that  position;  while  the  parts  are  thus  placed  upon  the 
stretch,  make  additional  point  pressure  with  the  end  of  the  finger  or 
thumb  upon  the  parts  thus  rendered  tense,  and  if  such  additional 
pressure  proiluces  retlcx  contractions,  that  tendon,  fascia,  or  muscle, 
must  be  divided,  and  the  point  at  which  the  reflex  spasm  is  excited 
is  the  point  where  the  operation  should  be  performed;  but  if  the  ad- 
ditional point  pressure  does  not  produce  reflex  contractions,  the  de- 
formity can  be  permanently  overcome  by  means  of  constant  elastic 
extension,  (c.)  The  paralysis  of  antagonizin<r  muscles  is  proved  by 
their  atrophy;  the  loss  of  voluntary  power  over  them;  their  insensi- 
bility to  the  electric  current:  and  finally,  by  the  congenital,  rather 
than  non-congenital,  nature  of  the  distortion,  the  former  being  gen- 
erally due  to  spasmodic  contraction  of  the  nmscles  involved,  and  the 
latter  to  paralysis  of  the  antagonizing  muscles.^ 

2.  The  instruments-  (Fig.  IGl)  are  tenotomes  of  different  con- 
struction. The  handles  should  be  so  marked  that  the  direc- 
tion of  the  blade  may  be  known  when  it  is  buried  in  the 
tissues;  the  shank  should  be  one  to  one  and  three  fourths 
inches  long;  stron'j,  and  firmly  inserted  into  the  handle; 
the  blade  should  be  three  quarters  of  an  inch  to  one  inch 
in  length,  very  thick  at  the  heel,  very  narrow  in  the  cutting 
portion,  and  always  blunt  pointed,  the  point  being  some- 
what rounded  and  .«liarpened  from  side  to  side,  like  a  wedge 
or  chisel,  so  that  it  will  split  rather  than  puncture  the  tis- 
sues; the  blades  are  of  various  shapes,  being  straight  or 
curved,  having  the  cuttinu  edge  on  the  convex  or  concave 
border;  the  steel  should  be  properly  tempered  to  prevent  pj^  jgj 
breaking  in  cutting  condensed  structures.     For  the  division 

of  fascia  a  longer  blade  is  re(]uired.  but  a  probe  point  is  preferable 
to  a  sharp  point.     (Fig.  162.) 

3.  The   operation   is   as   follows  ^r     Ana?sthetics   are    necessary 
in  severe  operations  ;   the  tendon  being  made  tense,  introduce  the 

tenotome  flatwise,  giv- 
^^  ^  ing  it  a  slight  rotary 

Pjj^  2(j.t  motion,  until  the  ten- 

don, muscle,  or  fascia 
is  reached;  carry  the  blade  flatwise  under  the  structure  to  its  oppo- 
site side,  then  turn  the  cutting  ed'j:e  towards  the  tissue  to  be  divided, 
Ihe  mark  on  the  handle  indicaiini:  the  directinn  of  the  edge;  press 
the  tendon  or  muscle  down  upon  the  blade,  at  the  same  time  crivinw 
the  instrument  a  slightly  sawing  motion  until  the  part  gives  way, 
1  W.  Adams.  2  L.  A.  Savre. 


204 


OPERATIVE  SURGERY. 


wliicli  can  be  recognized  by  the  finger,  and  often  by  a  snap;  the  di- 
vision being  made  complete,  turn  the  instrument  flatwise  and  with- 
draw it,  the  finger  or  thumb  following  and  forcing  out  any  blood  in 

the  track  of  the  knife 
and  preventing  the  en- 
trance of  air;  the  wound 
must  be  hermetically 
sealed  by  applying  two 
strips  of  adhesive  plaster 
which  cross  over  the  cut, 
but  do  not  surround  the 
limb,  and  secure  them 
by     a     roller     bandage. 

Fig.  163.  (^ig-  163.) 

4.  The  treatment  of 

the  divided  tissue  should  aim  to  secure  reunion  of  the  structure  of 
such  length  and  power  as  to  maintain  the  proper  balance  of  the 
forces  acting  on  the  part  previously  displaced.  In  order  to  effect 
this  object  the  deformed  part  must  be  restored  by  such  degrees  as 
will  not  prevent  the  union  of  the  several  tissues;  for  if  restoration 
is  complete  immediately  after  section,  the  smaller  tendons  may  be  so 
far  separated  that  union  will  not  take  place,  or  the  cut  ends  may 
unite  to  their  sheaths.  If  the  tendon  is  large,  as  the  tendo-Achillis, 
the  deformed  part  may  be  at  once  restored,^  but  if  the  tendon  is 
small,  as  the  posterior  tibial,  extension  should  be  gradual.^  The  ob- 
ject of  gradual  extension  is  not  so  much  to  elongate  or  stretch  the 
new  material,  as  to  regulate  its  length,  and  the  rate  at  which  this  is 
to  be  accomplished  must  depend  upon  the  activity  of  reparation  pro- 
cess, and  the  required  length  of  the  new  tendons. "■^  The  period  must 
therefore  vary  from  two  weeks  in  a  healthy  child,  to  tlu'ee  or  four 
weeks  in  the  adult,  and  to  five  or  six  weeks  in  atrophied  paralytic 
limbs. 

TEXOTOMV   IN    THE    UPPER    LIMBS. 

The  contractions  of  the  muscular  system  which  give  rise  to  distor- 
tions of  the  upper  limbs  are  very  numerous,  and  tend  to  seriously 
impair  function.  Distortions  of  the  fingers  are  peculiarly  disabling, 
and  require  judicious  treatment.  Tenotomy,  as  a  remedial  meas- 
ure, must  be  applied  with  great  care,  especially  in  the  region  of  the 
hand,  owinr;  to  the  extended  synovial  sheaths. 

1.  The  flexors  profundus  and  siiblimis  digitorum  arc  inserted 

into  the  jjhalanges  by  long  tendons  running   in  fibrous  sheaths  lined 

by  synovial  membrane.     The  deep  flexors  are  inserted  into  the  base 

of  the  third  row  of  phalanges,  and  the  superficial  flexors  into  those 

i  J.  Syuie;  L.  A.  Sayre.  2  ■v\r.  Adams. 


OPERATIONS  ON  THE  MUSCULAR  SYSTEM.      205 

of  the  second  row;  contraction  of  the  lon^  flexors  consequently 
flexes  the  third  phalanges,  and  contraction  of  the  superficial  flexors, 
the  second  row;  section  of  these  tendons  is  dan^a-rous,  owin;^  to  the 
liability  to  inflammation  of  the  sheatlis,*  and  should,  therefore,  be 
made  with  such  precautions  as  will  prevent  the  exposure  of  the  sy- 
novial surface  to  injury  or  septic  matter.  The  division  should  be 
made  on  tlie  first  or  second  phalanx.  The  knife  blade,  having  been 
wet  with  carbolic  solution,  enters  the  point  on  the  side  of  the  second 
phalanx,  near  the  anterior  surface,  and  having  reached  the  tendon, 
cut  to  the  bone;  withdraw  the  knife,  keeping  the  thumb  of  the  left 
hand  firmly  applied  to  the  wound  which  forces  out  any  blofxl;  the 
wound  should  instantly  be  hermetically  sealed,  and  several  days  be 
allowed  to  elapse  before  the  finger  is  fully  extended.  Section  of  the 
tendons  in  the  palm  is  still  more  dangerous,  owing  to  the  proximity 
of  arteries  and  nerves,  as  well  as  the  large  synovial  sheaths.  If  the 
attempt  is  made  to  operate  in  the  ])alm,  make  the  tendon  tense,  and 
puncture  anterior  to  the  transverse  fold  of  the  skin  to  avoid  the 
arterial  arches,  on  a  line  with  the  middle  of  the  metacarpal  bones, 
and  cut  directly  upon  the  bone;  close  the  wound  as  in  the  former 
case. 

2.  The  extensor  communis  digitorum  is  inserted  into  the  bases 
of  the  third  row  of  phalanges;  they  have  no  important  surgical 
relations  at  points  where  they  are  most  accessible,  namely,  the  dor- 
sum of  the  metacarpus.  Pinch  up  the  skin  over  the  tendon,  and 
avoiding  the  veins  and  articulations,  ])ass  the  tenotome  down  to  the 
tendon,  and  cut  towards  the  bone;  if  several  tendons  are  retracted, 
it  is  better  to  divide  each  separately,  rather  than  by  a  single  puncture, 
as  is  sunietimes  a<lvise<l. 

3.  The  extensors  primi  and  secundi  internodii  and  ossis 
metacarpi  pollicis,  may  fix  the  thumb  in  a  state  of  extension;  the 
radial  artery  passes  beneath  them  where  they  cross  the  carpus.  Sec- 
tion may  be  made  by  bringing  the  tendons  out  prominently;  fle.K  the 
extended  thumb  and  abduct,  which  will  make  the  extensors  ossis 
metacarpi  and  secundi  internodii  pollicis  prominent  below  the  sty- 
loid process  of  the  radius,  at  a  point  where  the  radial  artery  passes 
to  the  dorsum;  if  the  blunt  tenotome  is  inserted  through  an  incision 
while  the  tendons  are  made  tense,  and  kept  well  applied  to  it,  divis- 
ion may  be  made  without  danger.  The  extensor  primi  internodii 
pollicis,  King  more  external,  is  now  prominent,  and  may  be  divided 
safely  where  the  artery  ])asses  under  it,  over  the  second  phalanx. 

4.  The  flexor  carpi  radialis  runs  along  the  radial  side,  and  is 
inserted  into  the  base  of  the  second  metacarpal,  and  has  the  radial 
vessels  on  its  radial  border.     It  may  be  divided  above  the  wrist,  the 

1  T.  Billroth. 


206  OPERATIVE  SURGERY. 

tenotome  entering  on  the  radial  border  of  the  tendon,  made  tense, 
but  inside  of  tlie  radial  artery,  and  passed  beneath  it;  or,  if  neces- 
sary, the  palmaris  loncjns  may  be  divided  at  the  same  time;  first  cut 
the  palmaris  longus,  and  then  the  flexor  carpi  radialis. 

5.  The  flexor  carpi  ulnaris  runs  along  the  ulnar  border,  and  is 
inserted  into  the  pisifoi'm  bone,  and  has  the  ulnar  vessels  on  its 
radial  border.  It  can  be  safely  divided  by  making  it  tense,  and 
puncturing  on  the  radial  side,  and  keeping  the  blunt  tenotome  closely 
applied  to  the  tendon. 

G.  The  palmaris  longus  runs  down  the  middle  of  the  wrist,  is 
inserted  into  the  annular  ligament  and  palmar  fascia,  and  has  the 
median  nerve  on  its  ulnar  and  posterior  surface.  Section  is  effected 
while  the  tendon  in  made  prominent  by  passing  the  tenotome  on 
its  ulnar  side  carefully  under  it  above  the  wrist  or  near  its  insertion, 
avoiding  the  median  nerve,  and  cutting  towards  the  skin. 

7.  The  biceps  flexor  cubiti  is  inserted  into  the  tubercle  of  the 
radius;  it  lies  in  front  of  the  brachial  artery  and  median  nerve;  it 
firmly  flexes  the  forearm  when  permanently  contracted;  there  is  a 
marked  prominence  of  the  body  of  the  muscle,  and  an  elevated  cord 
or  band  at  the  bend  of  the  elbow  when  attempts  are  made  to 
straighten  the  limb.  Section  is  to  be  made  above  the  aponeurotic 
expansion  of  the  tendon,  the  contraction  of  Avhich  must  be  relieved, 
and  from  before  backwards.  Make  firm  extension  of  the  forearm, 
and  when  the  tendon  is  rigid,  insert  the  tenotome  at  the  external 
border,  avoiding  the  median  veins;  depress  the  handle  as  the  blade 
glides  under  the  skin  to  the  opposite  border,  turn  the  edge  to  the 
tendon  and  with  a  saAving  motion  divide  it;  the  brachial  artery  is 
half  an  inch  behind  the  tendon,  and  is  not  in  danger  unless  the 
incision  is  made  too  freely. 

8.  The  triceps  extensor  cubiti  is  inserted  into  the  olecranon 
and  has  no  other  important  feature  than  its  relation  to  the  joint  on 
its  under  surface.  Extension  of  the  forearm  is  caused  by  contraction 
of  the  triceps;  it  may  also  prevent  reduction  of  a  backward  disloca- 
tion. Section  should  be  made  by  puncture,  at  least,  an  inch  above 
the  joint,  and  on  the  inner  border,  to  avoid  the  ulnar  nerve;  flexion 
should  not  be  made  for  several  days,  and  then  gradually. 

9.  The  pectoralis  major  is  inserted  into  the  anterior  bicipital 
ridge  of  the  humerus,  and  tends  by  its  contraction  to  fix  the  arm  on 
the  front  of  the  chest;  it  forms  the  anterior  wall  of  the  axillary  cav- 
ity. In  section  the  tenotome  may  be  passed  along  its  anterior  or  pos- 
terior surface,  and  if  the  point  is  kept  in  contact  with  the  muscle, 
division  is  easily  effected  without  complication. 

10.  The  deltoid  is  inserted  into  the  middle  of  the  outer  sur- 
face of  the  shaft  of  the  humerus ;  its  origin  is  so  extensive  as  to  give 


OPERATIONS  OX  THE  MUSCULAR   SYSTEM.        207 

it  the  functions  of  several  muscles.  Section  may  be  made  of  differ- 
ent parts  of  its  insertion  acconlinn;  as  it  may  be  necessary  to  relieve 
contraction;  the  anterior  portion  by  insertin'^  the  tenotome  near  the 
insertion  from  Ijefore  backwards  aloni^^  its  internal  snrface  and  cut- 
ting to  the  skin,  and  the  posterior  margin  by  a  reverse  movement. 

11.  The  latissimus  dorsi  and  teres  major  are  inserted  into  the 
posterior  margin  of  the  bicipital  ridge,  and  form  the  posterior  wall 
of  the  axilla;  they  deiiress  the  arm  and  draw  it  backwards.  Section 
may  be  made  of  the  combined  muscles  by  passing  the  tenotome  alon^ 
either  surface,  turning  its  edge  to  the  muscles  and  dividing  with  a 
sawing  motion. 

TKXOTO.MY   IX    THE    LOWEU    LIMBS. 

The  distortions  of  the  lower  limb,  due  to  contractions  of  the  mus- 
cular system,  form  an  important  part  of  orthopedy.  The  differ- 
ent forms  of  club-foot  and  hand  are  due  largely  to  this  cause,  and 
are  remedied  by  restorinir  tlie  balance  of  muscular  forces. 

1.  The  flexor  longus  digitorum  affects  the  toes  so  as  to  require 
division,  only  when  its  contraction  aids  in  causing  or  maintaining 
other  distortions;  it  lies  in  such  immediate  relations  with  the  tibialis 
posticus  behind  the  malleolus,  that  if  the  knife  is  pushed  a  little 
deeper  when  behind  the  latter  tendon,  it  will  include  the  tendon  of 
the  former  muscle,  and  both  may  be  divided  at  the  same  operation; 
the  point  of  the  knife  should  be  moved  about  as  little  as  possible  to 
avoid  woundinir  the  posterior  tibial  artery. 

2.  The  flexor  longus  pollicis  may  require  section  to  liberate 
this  part  of  the  foot,  so  important  in  every  act  of  walking.  It  mav 
be  divided  on  the  first  phalanx, ^  or  near  the  inner  edge  of  the  foot, 
where  it  can  be  made  to  project  by  strong  extension  of  the  toe.  The 
point  of  division  should  de[>end  upon  the  prominence  of  the  tendon; 
by  carefully  passing  the  tenotome  alonir  the  tendon,  the  plantar  ar- 
teries will  esca[)e  injiny. 

3.  The  extensor  longus  digitorum  may  fix  the  toes  in  a  state  of 
extension,  or,  by  contraction,  may  elevate  the  anterior  part  of  the 
foot.  In  the  former  case,  section  of  separate  tendons  should  be  made 
on  the  dorsum  of  the  metatarsus  where  there  are  neither  important 
arteries  nor  nerves;  the  extensor  of  the  great  toe  often  requires  sec- 
tion also;  the  skin  may  be  pinched  up  and  the  tenotome  passed  be- 
tween it  and  the  tendon,  and  division  made  towards  the  bone.  In 
the  latter  case  section  shoubl  be  made  where  the  tendons  pass  over 
the  ankle;  enter  the  tenotome  close  to  the  inner  border  of  the  tendon 
made  tense,  pass  it  outwards,  and  when  the  point  is  at  the  extremest 
border  turn  the  edge  upwards. 

1  J.  Syme. 


208  OPERATIVE  SURGERY. 

4.  The  extensor  proprius  poUicis  has  upon  its  internal  bor- 
der below,  the  anterior  tibial  vessels  and  nerves  and  dorsalis  pedis 
artery.  Section  may  be  made  through  the  same  puncture  as  that 
used  for  section  of  the  long  flexor  of  the  toes,  the  point  of  the  knife 
being  turned  inwards,  and  carried  no  farther  than  the  internal  bor- 
der of  the  tendon  to  avoid  the  vessels  and  nerve.  Or,  being  made 
tense,  the  knife  may  be  inserted  on  its  inner  margin  and  passed  out- 
wardly. 

5.  The  tibialis  anticus  passes  from  the  annular  ligament  of  the 
ankle  over  the  internal  surface  of  the  tarsus,  and  is  inserted  into  the 
inner  and  under  surface  of  the  internal  cuneiform  bone  and  base 
of  the  metatarsal  of  the  great  toe.  In  talipes  varus  it  is  placed 
very  much  to  the  inner  side,  and  passes  obliquely  downwards  across 
the  inner  malleolus,  inclined  backwards  towards  the  internal  cunei- 
form bone,  Avhich  occupies  a  lateral  position,  owing  to  the  altered 
position  of  the  scaphoid  bone.  The  tendon  can  generally  be  easily 
felt,  except  in  fat  infants;  it  should  be  divided  a  Httle  above  its  in- 
sertion as  it  crosses  the  ankle  joint. 

C.  The  tibialis  posticus  passes  through  a  groove  behind  the  in- 
ner malleolus  with  the  tendon  of  the  flexor  longus  digitorum,  but  in 
a  sepirate  sheath,  then  through  another  sheath  over  the  internal 
lateral  ligament,  beneath  the  calcaneo-scaphoid  articulation,  and  is 
inserted  into  the  tuberosity  of  the  scaphoid  and  internal  cuneiform 
bone.i  The  posterior  tibial  artery  lies  behind  it.  In  talipes  varus 
the  tendon  at  the  point  of  division,  just  above  the  inner  malleolus, 
is  relatively  more  forward  than  in  the  healthy  foot,  and  in  the  sec- 
ond part  of  its  coui'se,  between  the  malleolus  and  its  insertion  into 
the  scaphoid,  the  tendon  does  not  pass  beneath  the  inner  malleolus, 
and  then  obliquely  downwards  and  forwards  to  its  insertion;  but  on 
the  contrary,  passes  directly  downwards  to  the  scaphoid  bone.^  If 
the  tendon  is  normal,  divide  it  half  an  inch  above  the  inner  ankle; 
the  posterior  tibial  artery  lies  posteriorly;  make  a  puncture  between 
the  artery  and  tendon,  turn  the  foot  outwards,  and  cut  towards  the 
skin;  the  artery  may  often  be  pressed  one  side  by  the  finger,  —  by 
the  nail  of  the  left  index  finger.  If  the  tendon  is  displaced,  as  in 
varus,  the  following  is  important:  If  neither  the  tendon  nor  the  inner 
edge  of  the  tibia  can  be  felt,  as  is  commonly  the  case  in  fat  infants, 
a  puncture  made  in  the  inner  aspect  of  the  leg  exactly  midway  be- 
tween the  anterior  and  posterior  borders,  is  a  true  guide  to  the  posi- 
tion of  the  tendon  at  the  point  of  section.  Thrust  the  tenotome  or 
a  sharp-pointed  knife  straight  down  to  the  tendon,  and  open  the 
sheath  by  a  movement  of  its  point;  now  insert  a  blunt-pointed  knife 
beneath  the  tendon,  which  will  at  once  be  so  fixed  that  it  cannot  be 
1  H.  Gray.  2  W.  Adams. 


OPERATIONS  OX  THE  MUSCULAR  SYSTEM.      209 

moved  from  side  to  side  if  it  is  between  tbe  tendon  ami  bone;  make 
a  complete  section  of  it. 

7.  The  peroneus  tertius  is  a  part  of  the  lonir  extensor,  and 
branches  oft"  to  be  inserteil  into  the  base  of  the  fifth  metatarsal. 
Section  is  readily  made  when  the  long  extensor  is  tense  !>}•  insertinif 
the  tenotome  on  its  external  margin  and  passing  it  inwards;  or  it 
may  lie  divided  at  the  same  time  with  the  long  extensor. 

8.  The  peroneus  longus  aud  brevis  pass  through  the  same 
groove  behind  the  external  malleolus,  and  are  invested  by  a  common 
fibrous  and  synovial  sheath;  the  long  peroneus  then  passes  across  the 
outer  side  of  the  os  calcis,  in  a  separate  sheath,  over  the  margin  of 
the  cuboid,  across  the  foot  to  the  base  of  the  first  metatarsal;  the 
short  peioneus  j)asses  on  the  outer  side  of  the  os  calcis  to  the  base  of 
the  fifth  metatarsal  bone.  Section  of  these  tendons  may  be  made: 
(1.)  An  inch  al)ove  the  base  of  the  external  malleolus,  the  tenotome 
entering  fiom  before  backwards  between  the  fibula  and  the  tendons; 
or,  (2.)  half  an  inch  in  front  of  the  apex  of  the  malleolus,  where  they 
may  be  niade  prominent  and  divided  by  a  single  puncture;  or,  (3.) 
the  long  tendon  could  be  divided  at  a  point  midway  lietween  the  end 
of  the  malleolus  and  the  tubercle  of  the  cuboid,  and  the  short  tendon 
at  the  external  border  of  the  extensor  brevis  digitoruin. 

9.  The  tendo-Achillis  is  about  six  inches  long,  commencinor 
about  the  middle  of  the  leg,  and  is  inserted  into  the  lower  part  of 
the  tuberosity  of  the  os  calcis;  it  is  separated  from  the  deep  vessels 
by  a  considerable  interval;  the  external  saphenous  vein  runs  along 
its  outer  side;  section  is  made  as  follows:  Place  the  patient  on  his 
stomach  with  the  foot  hanging  over  the  table  or  bed;  an  assistant 
shoidd  put  the  tendon  on  the  stretch  by  attempting  to  fle.x  the  foot; 
introduce  the  tenotomy  knife  obliquely  downward  with  its  flat 
surface  parallel  witli  the  tendon,  close  to  its  inner  or  outer  edore, 
as  most  convenient,  when  the  tendon  is  prominent;  but  when  the 
tendon  is  deep,  enter  the  knife  on  the  fibular  side  to  avoid  the  possi- 
bility of  puncturing  the  posterior  tii)ial  artery;  carry  the  knife  to 
the  opposite  side,  depressing  the  handle  to  a  horizontal  direction  ; 
now  turn  the  cutting  edge  towards  the  tendon  and  divide  it  trans- 
vei'sely  from  the  internal  to  its  external  surface;  close  the  wound 
with  a  compress  fixed  by  adhesive  strip  and  bandage.  If  the  foot  is 
immediately  restored,  it  must  be  retained  in  position  by  a  proper 
shoe  or  by  adhesive  strips  passed  around  the  anterior  part  of  the 
foot,  and  fastened  to  the  upper  part  of  the  leg.  If  reduction  is 
to  be  gradual,  these  appliances  should  not  be  resorted  to  in  three  or 
four  (lavs. 

10.  The  biceps  flexor  cruris  is  inserted  into  the  head  of  the 
fibula,  and   forms  the  external   hamstring;   the   external    popliteal 

14 


210  OPERATIVE  SURGERY. 

nerve  lies  close  to  its  internal  border.  Place  the  patient  in  a  prone 
position,  extend  the  leg  firmly,  and  recognize  the  tendon;  enter  the 
tenotome  an  inch  above  the  head  of  the  fibula,  on  its  inner  border, 
inclining  it  at  first  outwards,  until  its  point  passes  under  the  tendon; 
then  depress  the  handle  to  the  horizontal,  and  when  its  point  is  felt 
on  the  opposite  side,  turn  the  edge  upwards  towards  the  tendon  and 
divide. 

11.  The  semi-tendinosus,  semi-membranosus,  gracilis,  and 
sartorius,  form  the  inner  hamstring,  and  are  inserted  upon  the  inner 
and  anterior  surface  of  the  tibia;  the  nerves  and  vessels  of  this  re- 
gion lie  quite  external.  The  patient  being  in  a  prone  position,  enter 
the  probe-pointed  knife  close  to  the  outer  side  of  the  tense  hamstring 
to  avoid  the  vessels  and  nerves  of  the  ham,  incline  it  inwards 
towards  the  median  line  of  the  body  as  it  passes  under  the  mus- 
cles, and  until  its  point  is  felt  on  the  inner  side;  now  depress  the  han- 
dle and  divide  the  structures  towards  the  skin;  the  section  may  be 
limited  to  tlie  semi-tendinosus  and  membranosus,  or  by  deeper  pene- 
tration all  the  tendons  and  muscles  forming  this  group  may  be  safely 
divided. 

12.  The  quadriceps  extensor  cruris  is  composed  of  the  rectus, 
vastus  externus  and  internus,  and  crureus;  the  tendon  is  inserted 
into  the  tubercle  of  the  tibia  through  the  medium  of  the  patella  and 
the  ligamentum  patella ;  a  large  bursa  lies  under  the  conjoined  ten- 
dons above  the  patella.  Section  above  the  patella  is  made  as  fol- 
lows: pinch  up  a  fold  of  skin  parallel  with  the  ligament;  pass  the 
tenotome  through  to  the  tendon,  but  do  not  penetrate  too  deeply; 
carry  the  blade  along  the  anterior  surface  under  the  skin;  turn  it 
towards  the  tendon,  and  with  a  sawing  motion  cut  until  all  resist- 
ance ceases;  effectually  close  the  wound,  and  do  not  attempt  flexion 
until  the  repair  has  begun. 

13.  The  pectineus  is  situated  at  the  anterior  part  of  the  upper 
and  inner  aspect  of  the  thigh,  extending  from  the  ilio-pectineal  line 
of  the  pelvis  to  the  rough  line  below  the  trochanter  minor;  it  is 
an  adductor  of  the  thigh  and  may  be  divided  as  follows:  ^  While  one 
assistant  fixes  the  pelvis,  and  a  second  straightens  the  contracted 
thigh,  recognize  the  tense  and  elevated  tendon  of  the  muscle  and 
pass  a  long  blunt  tenotome  blade  under  it  from  the  external  side,  an 
inch  and  a  half  below  its  origin;  with  a  few  passes  of  the  blade  the 
entire  muscle  is  divided  towards  the  skin,  or  the  section  may  be  made 
from  the  skin. 

14.  The  adductor  longus  lies  on  the  same  plane  as  the  pectineus; 
it  arises  by  a  flat  narrow  tendon  from  the  angle  of  junction  of  the 
crest  with  the  symphisis,  where  it  may  be  readily  severed.     Abduct 

1  F.  Stroniever. 


OPERATIONS   ON  THE  MUSCULAR  SYSTEM.      211 

the  tliij^li  and  make  the  muscle  prominent  near  its  insertion.  Pass 
the  tenotome  from  without  downward  and  inward,  until  the  muscle 
is  passed;  then  cut  with  a  sawing  motion  towards  the  skin  until  the 
contracted  tissue  is  divided. 

15.  The  tensor  vagiiice  femoris  is  a  short,  flat  muscle  arisinor 
from  the  anterior  part  of  the  outer  lip  of  the  crest  of  the  ilium,  and 
from  the  outer  surface  of  the  anterior  superior  spinous  process,  and 
terminates  in  the  fascia  lata  of  the  thigh,  one  fourth  down  the  ex- 
ternal aspect  of  the  thigh.  It  is  easily  divided  hy  making  it  tense 
an<l  passing  a  tenotome  on  either  border  about  an  inch  from  its  origin, 
and  cutting  towards  the  skin. 

16.  The  sartorius  arises  by  tendinous  fil)res  from  the  anterior  su- 
perior spinous  process  of  the  ilium,  and  the  upper  half  of  the  notch 
below  it.  Make  a  section  of  its  tendon  thus:  An  assistant  strongly 
abducts  the  thigh,  which  makes  the  muscle  prominent;  pass  the  long 
blunt  tenotome  under  the  muscle  on  its  external  border  two  and  a 
half  inches  from  its  origin  and  cut  towards  the  skin. 

TEXOTOMY    IX    THE    TRUXK. 

Many  of  the  muscles  in*  the  region  of  the  back  have  been  divided 
to  relieve  curvature  of  the  spine. ^  The  first  effect  of  division  of  con- 
tracted muscles,  as  the  latissimus  and  longissimus  dorsi  in  lateral  cur- 
vature, was  in  some  cases  instantly,  apparently,  very  beneficial."^  But 
in  no  instance  has  the  operation  itself  produced  a  cure,  its  effect 
being  simply  to  take  off,  either  in  part  or  whole,  the  power  of 
muscles  engaged  in  maintaining  the  curvature,  and  thus  placing  the 
spine  in  a  condition  to  be  more  easily  influenced  by  mechanical  and 
physiological  causes. ^ 

1.  The  multifidus  spinee  consist  of  a  number  of  fleshy  and  ten- 
dinous fasciculi  which  fill  up  the  groove  on  either  side  of  the  spinous 
processes  from  the  sacrum  to  the  axis.  The  tension  of  the  deep- 
seated  layer  of  muscles  of  the  back  is  weakened  by  dividing  the 
thickest  part  of  this  muscle,  as  it  lies  comparatively  superficial  upon 
the  dorsum  of  the  sacrum  opposite  the  posterior  superior  spine  of 
the  ilium  ;  ^  pinch  up  the  skin  so  that  the  fold  is  parallel  with  the 
spine;  pass  the  tenotome  upon  the  surface  of  the  muscle,  and  cut 
towards  the  spine. 

2.  The  longissimus  dorsi  and  sacro  lumbalis  are  portions  of 
the  erector  spinse;  the  former  is  the  inner  and  larger  portion,  and  is 
inserted  into  the  tips  of  the  transverse  processes  of  the  dorsal  ver- 
tebrjp,  and  into  seven  to  eleven  ribs ;  the  latter  is  the  external  and 
smaller  portion,  and  is  inserted  into  the  angles  of  the  six  lower  ribs. 
The  tension  of  the  middle  layer  of  spinal  muscles  is  relieved  by  di- 

1  Gudrin.         ^  Report  of  Committee  on  Gueriu's  Practice.        3  \i.  Hunter. 


212 


OPERATIVE  SURGERY. 


viding  these  muscles  in  the  lumbar  region  near  their  origin;  ^  operate 
as  above. 

3.  The  latissimus  dorsi  covers  the  lumbar  and  lower  half  of  the 
dorsal  regions,  and  is  inserted  into  the  bicipital  groove  of  the  hume- 
rus. The  muscle  is  made  tense  by  elevating  the  shoulder  forcibly, 
and  may  be  divided  as  follows :  ^  Select  a  long,  strong  tenotome; 
pass  the  point  under  the  anterior  edge  of  the  muscle,  nearly  opposite 
the  angle  of  the  scapula,  and  along  the  under  surface;  now  turn 
the  edge  towards  the  muscle  and  cut  with  a  short  sawing  motion, 
the  thumb  being  pressed  upon  the  tightly  drawn  band  ;  turn  the 
knife  upon  its  side  and  withdraw  it,  closing  the  wound  with  the 
thumb;  dress  the  wound  with  adhesive  plaster  and  firmly  adjusted 
roller.- 

4.  The  trapezius  has  one  origin  from  the  superior  curved  line 
and  protuberance  of  the  occiiatal  bone.  In  lateral  deviations  of  the 
head  this  muscle  may  become  permanently  contracted  and  require 
division  at  its  cranial  origin.  The  muscle  being  made  tense  by  car- 
rying the  head  to  the  oppo.-^ite  side,  enter  the  tenotome  below  the 
occipital  protuberance,  pass  its  blade  along  the  external  surface  of 
the  muscle,  then  turn  its  edge  to  the  muscle^and  divide  the  contracted 
tissue. 

The  sterno-cleido-mastoid  muscle  has  its  origin  from  the  upper 
part  of  the  sternum  by  a  flat  tendon,  and  from  the  sternal  third  of 
the  clavicle  by  fleshy  fibres;  behind  it  are  the  carotid  and  subclavian 
arteries,  and  internal  jugular  vein.  Division  of  this  part  of  the 
muscle  is  necessary  in  distortion  of  the  head,  wryneck  or  torticollis, 
when  it  depends  upon  unyielding  contraction  of  the  sterno-mastoid 
without  caries  of  the  spine.  In  some 
cases  only  the  clavicular  portion  needs  to 
be  divided.  The  operation  is  perfectly 
free  from  danger,  if  carefully  performed, 
since  the  muscle  stands  out  well  from  the 
vessels  below  it,  which  are  again  separ- 
ated by  a  strong  membrane.^  A  separ- 
ate puncture  should  be  made  for  each 
portion  of  the  muscle.  An  assistant 
should  put  the  head  on  the  stretch  so 
as  to  render  the  muscle  prominent  (Fig. 
164),  pass  a  long  tenotome  closely  along 
the  surface  of  the  clavicular  fibres  about 
half  an  inch  above  the  clavicle,  turn  its 
edge  towards  the  muscle  and  divide  completely;  enter  the  teno- 
tome in  the  same  manner  and  divide  the  sternal  origin. 

1  R.  Hunter.  2  L.  A.  Sayre.  3  T.  Holmes. 


Fig.  1G4. 


IV. 

THE    CIRCULATORY    SYSTEM. 

THE    HEART;    THE    ARTERIES;    THE    CAPILLARIES; 
THE  VEINS;  THE  LYMPH  A  TICS. 


CHAPTER   XXI. 

THE   INJURIES   OF   THE    CIRCULATORY  SYSTEM  AND 
SPECIAL   OPERATIONS. 

I.   THE    HEART. 

Wounds  may  involve  only  the  i)orie<irdiiini,  or  they  may  pene- 
trate to  the  walls  of  the  heart,  or  even  reaeh  its  cavities.  The  in- 
struments with  which  they  are  inflicted  are  projectiles  and  pointed 
bodies,  as  needles,  pins,  knives.  The  symptoms  are,  ha;morrhage 
from  the  wound,  more  or  less  free;  sudden  convulsive  movement;  pal- 
lor; faintness;  si<iliinj;  respiration ;  cold  extremities;  small,  unequal, 
and  intermittinj^  pulse,  and  acute  pain  in  the  sternal  region.  Death 
may  be  immediate,  caused  by  the  sudden  arrest  of  the  heart's  ac- 
tion, either  from  shock  or  the  accumulation  of  blood  in  the  peri- 
cardium, or  life  may  be  prolonged  for  days,  or  complete  recovery 
may  follow.  The  treatment^  should  aim  (1)  to  favor  the  formation 
of  a  coagulum  in  the  wound;  close  it  with  antiseptic  dressings  at 
once,  and  do  not  reopen  unless  the  collection  of  blood  in  the  peri- 
cardium becomes  so  great  as  to  cause  intense  dyspncea  ami  interfere 
materially  with  the  action  of  the  heart ;  place  the  patient  in  a  re- 
cumbent position,  and  enforce  the  strictest  quiet  and  silence;  freely 
expose  the  chest  to  the  air,  and  if  there  is  a  tendency  to  liajmor- 
rhage,  apply  cold,  as  ice;  remove  any  foreign  body  when  it  can  be 
effected  without  didicidty,  but  use  no  violence  in  attemptiuLT  to  with- 
draw it  lest  fatal  hivmorrliage  ensue;  (2.)  prevent  the  se])aration  of 
the  clot;  persistent  rest  of  the  body  in  the  recumbent  position,  and 

1  J.  F.  West. 


•21i  OPERATIl'E  SURGERY. 

removal  of  all  sources  of  irritation,  local  or  general,  must  be  enforced 
for  a  considerable  period;  venesection  is  not  required,  but  diiritalis 
to  moderate  the  force  of  the  heart's  action,  acetate  of  lead  to  favor 
congulation  of  the  blood,  and  hypodermic  injections  of  morphia  to 
allay  excitement,  ■will  be  required;  interfere  with  the  wound  as  little 
as  possible;  (3)  to  control  inilammation;  leeches,  perfect  rest,  low 
diet,  with  calomel  and  opium,  are  most  useful;  in  all  cases  a  broad 
flannel  bandage  applied  around  the  thorax  gives  the  greatest  com- 
fort. If  the  prajcordial  dullness  becomes  very  extensive  from  serous 
effusion  into  the  pericardium,  or  if  still  later,  there  is  evidence  of 
a  collection  of  pus,  it  will  be  expedient  to  draw  off  the  fluid  with  a 
trocar  or  aspirator,  the  cicatrix  being  the  guide  to  the  point  of  punc- 
ture. AA'hen  a  foreign  body  remains  and  the  diagnosis  has  been  sat- 
isfactorily established,  extraction  by  incision  has  been  undertaken 
with  success,  as  follows  :  ^  Chloroform  being  given,  a  spot  was  selected 
at  which  each  impulse  of  the  heart  gave  the  feeling  of  something 
firmer  than  the  surrounding  tissue;  the  skin  and  subcutaneous  struc- 
tures were  divided,  when  the  extremity  of  the  needle  was  brought 
into  view  on  a  level  with  the  surface  of  the  intercostal  muscle  moving 
with  each  impulse  of  the  heart,  and  describing  a  curve;  the  needle 
was  now  seized  and  removed. 

II.   ARTERIES. 
The  deep  situation  of  arteries,  and   their  unexposed  position   at 
joints,  protect  them  from  the  more  common  injuries. 

1.  Contusion  may  be  so  slight  as  to  cause  but  temporary  dis- 
turbance of  the  circulation,  or  so  severe  as  to  lead  to  closure  of  its 
calibre,  or  destruction  of  its  coats.  Closure  is  due  to  the  formation 
of  a  thrombus,^  and  is  liable  to  be  followed  by  gangrene  of  the  parts 
supplied  by  the  artery.  If  a  lesion  of  the  coats  finally  occurs,  a 
pulsating  tumor,  traumatic  aneurism,  forms.  The  treatment  of  con- 
tusion depends  upon  its  secondary  effects;  if  gangrene  follows,  am- 
putation will  be  required  Avhen  the  disease  has  become  limited;  if 
an  aneurism  appears  it  must  be  treated  according  to  the  rules  estab- 
lished. 

2.  Rupture  of  the  coats  of  an  artery  occurs  when  the  limb  is  sub- 
jected to  a  violent  strain.  The  lesion  may  involve  the  internal  coat 
only,  or  the  external  coats  without  lesion  of  the  internal  coat,  or  all 
of  the  coats  may  be  torn  through.  The  symptoms  depend  upon 
the  nature  of  the  lesion ;  if  the  internal  coat  alone  is  ruptured,  there 
is  sudden  pain  in  the  part,  and  the  circulation  ceases.  The  artery 
is  finally  closed,  as  in  ligature  at  the  point  of  injury.  Lesion  of  the 
external  coats  is  followed  by  pain,  and  a  pulsating  tumor,  an  aneu- 

1  G.  W.  Callender.  2  jj.  Moxoa. 


INJURIES   OF   THE   CIRCULATORY  SYSTEM.      215 

rism.  If  all  the  coats  are  riijitured,  extravasation  to  a  variable  extent 
takes  plaee  into  the  snrrouiidiiif;  tissues,  with  diffused  swelling.  If 
the  Ijlood  is  eft'use<l  in  larj^e  quantities  from  a  ruptured  artery  of  an 
extremity,  as  from  the  popliteal,  wliieh  is  most  frequently  injured, 
ganirrene  will  soon  follow.  If  the  extravasation  takes  place  slowly, 
or  to  a  limited  extent,  the  conditions  of  an  aneurism  are  gradually 
developed.  The  treatment  must  depend  upon  the  degree  of  injury 
to  the  artery;  if  blood  is  effused  in  small  quantities,  rest,  position, 
and  cold,  witli  pressure  upon  the  distal  portion  of  the  trunk,  may 
effect  a  cure;  if  there  is  large  effusion,  without  coldness  of  the  limb 
below,  apply  a  tourniciuet,  or  the  elastic  bandage  above,  cut  down 
upon  the  ruptured  artery,  turn  out  the  clot,  find  the  rent,  and  tie 
above  and  below;  if  the  extravasation  is  excessive,  followed  by  cold- 
ness and  numbness  of  the  extremity,  amputate  at  once  above  the 
seat  of  iiijm-y. 

3.  Penetrating  wounds  bj-  a  small  instrument,  as  a  needle,  will 
heal  without  haemorrhage  or  other  symptom.  If  the  instrument  is 
large,  luemorrhage  may  be  immediate,  or  the  elasticity  of  the  coats 
may  close  the  wound  temporarily,  but  it  is  liable  to  reopen  and  bleed. 
If  the  wound  is  incised  it  maybe  transverse,  oblique,  or  longitudinal 
to  the  axis  of  the  vessel;  it  may  parlially  or  wholly  divide  the  artery; 
in  conq)lete  division  there  is  less  liability  to  haemorrhage  than  in 
partial  division,  owing  to  the  contraction  and  retraction  in  the  for- 
mer case;  longitudinal  incised  wounds  tend  to  unite  without  dress- 
ing. The  treatment  should  be  as  follows:  (1.)  Remove  any  foreign 
body  from  the  wound  which  might  interfere  with  the  closure  of  the 
artery;  (2.)  arrest  the  hajmorrhage  according  to  the  following  gen- 
eral rules:  — 

(rt.)  If  the  wounded  artery  is  in  an  extremity,  the  ha-morrhage  may  be  tem- 
porarily controlled,  either  by  strongly  flexing,  or  by  very  forcibly  extending  the 
limb  (in  the  former  case  the  artery  is  compressed  at  the  bend  of  the  limb,  and 
in  the  latter  compression  is  made  in  its  course  by  the  muscles  and  the  fasciae); 
(b.)  in  all  cases  of  punctured  wounds,  when  pressure  can  be  effectually  made, 
and  especially  against  a  bone,  it  should  be  tried  by  graduated  compression  over 
the  part  injured  (Fig.  1G5)  and,  if  necessary,  on 
the  artery  above  and  below  the  wound;  if  it  is 
in  an  extremity,  bandage  the  whole  limb,  the  mo- 
tions of  which  should  be  effectually  prevented, 
and  absolute  rest  must  be  enjoined,  especially 

if   the  artery  is  large;    continue  this  treatment  tlG-  Itio. 

for  two,  three,  or  more  weeks,  according  to  the  nature  of  the  injury;  (c.)  if  the 
artery  is  small,  like  the  temporal,  divide  the  vessel,  when  it  will  be  enabled  to 
retract  and  contract;  and  the  bleeding  will  in  general  permanently  cease  under 
pressure,  especially  when  it  lan  be  ap|)lied  against  the  hone.  If  die  artery  is 
of  a  larger  class,  and  continues  to  bleed,  it  shoidd  be  sufficiently  exposed  by 
enlarging  the  wound;  a  ligature  should  be  applied  above  and  below  the  opening 


216  OPERATIVE  SURGERY. 

in  the  vessel,  which  mrty  or  may  not  be  divided  between  them.  If  it  is  deter- 
mined to  apply  a  ligature,  it  is  a  rule  that  no  operation  is  to  be  done  for  a  wounded 
artery  in  the  first  instance  but  at  the  spot  injured,  unless  such  operation  not  only 
appears  to  be,  but  is  impracticable.  No  operation  should  be  performed  if  bleed- 
ing has  ceased,  unless  its  repetition  would  endanger  life.i 

AVounds  of  certain  arteries  require  special  treatment,  as  follows:  — 

1.  In  the  neck.  (1)  Wlien  the  internal  carotid  is  wounded  through  the 
mouth,  place  a  ligature  above  and  below  the  opening  made  into  it;  2  ilie  rule 
which  generally  obtains  among  surgeons  is  to  apply  a  ligature  to  the  common 
carotid;  (2)  when  any  one  of  the  branches  of  the  external  carotid  has  been 
wounded,  tie  l)oth  ends  at  the  part  wounded;  if  this  is  impracticable,  and  the 
haemorrhage  demands  it,  the  trunk  of  the  external  carotid  should  be  ligated,  not 
the  common  carotid;  (3)  the  internal  carotid  artery,  when  wounded  near  the 
bifurcation  of  the  common  carotid,  is  to  be  secured  by  two  ligatures;  (4)  a 
ligature  may  be  placed  on  the  internal  or  external  carotid,  close  to  the  bifurca- 
tion, with  safety;  but  if  the  wound  of  either  vessel  should  encroach  on  the  bi- 
furcation, one  ligature  should  be  applied  on  the  common  trunk,  and  another 
above  the  part  wounded;  but  as  neither  of  these  would  control  the  collateral 
circulation  through  the  uninjured  vessel,  whichever  of  the  two  it  might  be,  a 
third  ligature  should  be  placed  on  it  above  the  bifurcation;  (5)  a  wound  known 
or  suspected  to  be  of  the  vertebral  artery  should  be  treated  either  by  direct 
pressure  or  by  ligature  of  the  vessel  in  the  wound^;  (6)  never  place  a  ligature 
on  the  subclaVian  artery  above  the  clavicle  for  a  wound  of  the  axillary  below  it. 

1.  In  the  upper  limb.  (1)  In  punctured  wounds  of  the  arteries  of  the  arm 
and  forearm  apply  pressure  to  the  part  injured,  and  a  bandage  to  the  limb  gen- 
erally; but  when  the  bleeding  cannot  be  restrained  in  this  manner,  a  ligature 
should  be  applied  above  and  below  at  the  part  injured  whether  the  artery  be 
radial,  ulnar,  or  interosseal;  (2)  when  the  ulnar  artery  is  wounded  in  the  hand, 
which  is  comparativelj' a  superficial  vessel,  pressure  may  first  be  tried;  but 
failing,  apply  ligatures  upon  each  extremity;  (3)  when  the  radial  artery  is 
wounded  in  the  hand,  in  which  situation  it  is  deep  seated,  and  the  bleeding  end 
or  ends  of  the  artery  can  be  seen,  place  a  ligature  on  each;  if  this  cannot  be 
done,  search  by  incisions  through  the  fascia,  as  extensively  as  the  situation  of 
the  tendons  and  nerves  in  the  hand  will  permit,  that  the  bleeding  point  may 
be  fully  exposed,  remove  all  coagula,  lay  a  piece  of  lint,  rolled  tight  and  hard, 
of  a  size  only  sufficient  to  cover  the  bleeding  point,  upon  it;  place  a  second 
and  larger  hard  piece  over  it,  and  so  on,  until  the  compresses  rise  so  much 
above  the  level  of  the  wound  as  to  allow  the  pressure  to  be  continued  and 
retained  on  the  proper  spot,  without  including  the  neighboring  parts;  apply 
a  piece  of  linen,  constantly  wet  and  cold,  over  the  sides  of  the  wound,  which 
should  not  be  closed,  to  allow  of  the  free  escape  of  blood.  It  is  desirable  to 
ligate  the  brachial  artery  rather  than  the  radial  and  ulnar  in  secondary  haemor- 
rhage of  liand.i 

3.  In  the  lower  limb.  (1)  The  anterior  tibial  artery  is  to  be  tied  at  that  part 
of  its  course  at  which  it  may  be  wounded;  if  the  wound  is  very  near  its  origin, 
or  just  behind  the  interosseous  space  and  ligament,  and  the  bleeding  free, 
make  an  incision  on  the  fore  part  of  the  leg,  and  if  the  bleeding  point  is  so  deep 
between  the  bones  as  not  to  admit  of  two  ligatures  being  placed  on  the  artery 
above  and  below  it,  make  an  incision  through  the  calf  of  the  leg,  when  the  ar- 
ter3-  can  be  secured  without  difficulty;  (2)  the  posterior  tibial,  or  the  peroneal 

1  C.  F.  Maunder.  '^  C.  J.  Guthrie.  3  T.  Holmes. 


INJURIES  OF  THE   CIRCULATORY  SYSTEM.        217 

arttrv,  or  l)otli,  if  wounded  at  the  same  time,  are  to  be  tied  through  a  free  in- 
cision in  the  calf;  (3)  the  popliteal  artery  should  be  secured  by  ligature,  only 
when  bleedinj;;  (4)  when  a  wound  of  the  femoral  artery  or  its  branches  occurs, 
and  the  bleeding  cannot  be  restrained  by  a  moderate  but  regulated  compression 
on  the  trunk  of  the  ve-ssel,  and  perhaps  on  the  injured  t>art,  recourse  should  be 
had  to  an  operation,  by  which  both  ends  of  the  wounded  artery  may  be  secured 
by  ligature;  and  the  inipraclicability  of  doing  this  should  be  ascertained  only 
by  the  failure  of  the  attempt;  if  the  lower  end  of  the  artery  cannot  be  found  at 
the  time,  the  upper  only  having  bled,  a  gentle  compression  maintained  njwn  the 
track  of  the  lower  may  prevent  mischief;  but  if  dark-colored  blood  should  flow 
from  the  wound,  which  may  be  expected  to  come  from  the  lower  end  of  the 
artery,  and  compression  does  not  suffice  to  suppress  the  luemorrhage,  the  bleed- 
ing end  of  the  vessel  must  be  exposed,  and  secured  near  to  its  extremity;  (5.) 
wounds  of  the  branches  of  the  internal  iliac  require  that  a  ligature  should  be 
applied  to  both  cut  extremities,  and  not  to  the  arteries  at  their  origin. 

III.    THE  VEINS. 

The  vt'ins  are  liable  to  traumatic  lesions,  but  owin,'  to  tlie  quiet 
flow  of  the  blood-current,  and  the  coni|)res.sion  of  surrounding  tis- 
sues, the  effusion  is  rarely  serious.  When,  however,  injuries  of 
dee[>-seated  veins,  especially  those  communicating  with  cavities,  oc- 
cur, the  haemorrhage  may  be  dangerous. 

1.  Contusion  ^  causes  the  rupture  of  a  greater  or  less  number  of 
superficial  veins,  followed  by  the  extravasation  of  blood  into  the  sur- 
rounding tissues,  or  into  cavities.  The  more  vascular  and  yielding 
a  part,  and  the  more  severely  contused,  the  greater  the  extravasation; 
if  the  blood  escapes  slowly  it  forms  a  passage-way  between  the  con- 
nective-tissue bundles,  especially  subcutaneous  connective-tissue  and 
muscles,  the  wounds  being  rough  and  ra.rged,  obstacles  are  pre- 
sented to  the  free  escape  of  blood,  and  fibrinous  clots  form,  extend- 
ing into  the  calil)re  of  the  vessel,  causing  mechanical  closure  by 
tlironibnses.  The  escaped  blood  undergoes  various  chanires,  namely: 
the  filirine  coagulates,  the  serum  enters  the  connective  tissue  and  is 
ve-absori)ed,  the  coloring  matter  leaves  the  blood- corpuscles  and  is 
distributed  in  solution  among  the  tissues,  passing  through  various 
metamorphoses,  with  change  of  color  till  it  is  transformed  into  hema- 
toidin;  tlie  fibrine  and  blood  corpuscles  for  the  most  part  undergo 
disorjijanization  and  are  re-absorbed.  The  effused  blood  assumes 
different  conditions :  (1.)  Sug<_dllation  is  a  diffuse,  subcutaneous 
hajmorrhage,  of  a  dark  blue  color,  which  chau'jes  into  a  {jreen,  and 
then  into  a  brighty  ellow,  which  remains  for  a  iou'^  period.  Re-ab- 
sorption usually  takes  place,  owing  to  the  diffusion  of  the  blood,  and 
the  good  condition  of  the  vessels;  apply  cold  to  prevent  further  ex- 
travasation, and  spirit  or  stimulating  lotions  to  promote  absor|)tion. 
(2.)  Ecchymosis  is  the  accumulation  of  blood  into  a  circumscribed 
1  T.  Billroth. 


218  OPERATIVE  SURGERY. 

space  of  connective  tissues,  and  may  be  superficial  with  a  dark  blue 
color,  or  deep  without  discoloration  ;  fluctuation  is  often  very  dis- 
tinct. The  blood  will  have  the  same  fate  as  the  contused  tissues;  if 
they  return  to  their  normal  state,  re-absorption  will  follow;  but  if  they 
are  broken  down  and  pass  into  disintegration  or  decomposition,  the 
blood  collection  will  under<;o  the  same  change.  Innncdiately  after 
the  accident  apply  compression  as  accurately  as  jjossible  to  the  rup- 
tured vessel  to  prevent  further  effusion;  apply  ice,  or  cold  lotions, 
to  prevent  inflammation;  employ  uniform  compression,  with  moist 
dressings  to  promote  absorption;  if  there  is  no  marked  change  in 
two  weeks,  to  compression  add  painting  with  tr.  iodine  daily;  if  it 
become  hot,  red,  and  painful,  apply  warm,  moist  dressings,  as  poul- 
tices, and  wait  for  thinning  of  the  skin  over  the  forming  abscess 
before  opening  it;  if  the  tension  and  swelling  rapidly  increase,  with 
chills  and  fever,  the  blood  and  pus  are  decomposing,  and  the  contents 
must  be  evacuated  by  free  incision,  and  the  cavity  cleansed  and 
dressed  with  carbolic  solution. 

2.  Wounds  of  veins  are  of  frequent  occurrence,  and  generally  of 
slight  importance.  They  are  recognized  by  the  flow  of  dark  blood 
without  jet  or  impulse.  They  heal  readily,  owing  to  the  easy  ap- 
proximation of  the  cut  surfaces,  and  the  prompt  formation  of  the 
blood  clot  in  the  wound  and  vessel.  The  danger  is  three-fold, 
namely,  haemorrhage;  the  entrance  of  air;  inflanmiation  in  the  con- 
nective tissue  with  the  formation  of  thrombus.  Ligate  the  vein,  if 
exposed  and  accessible,  or  use  torsion  or  acupressure;  elevate  the  limb 
or  j)art,  and  remove  all  constriction  above  the  wound;  apply  firm 
compression  over  the  wound;  prevent    inflammation  by  the  use  of 

cold. 

V.    THE  LYMPHATICS. 

Wounds  1  of  the  lymphatic  vessels  occur  in  every  considerable 
wound  of  the  soft  tissues,  but  their  injury  is  concealed  by  the  flow 
of  blood,  and  the  lesions  of  other  vessels.  It  is  only  by  the  subse- 
quent inflammation  that  their  lesions  become  important.  From  the 
margins  of  the  wound  fine  red  strise  run  longitudinally  towards  the 
glands,  which  swell  and  become  very  sensitive,  accompanied  by 
fever,  loss  of  appetite,  and  general  depression.  The  inflammation 
may  terminate  in  resolution,  or  the  limb  may  become  red  and  cedem- 
atous,  with  high  fever,  and  even  chills,  and  fluctuation  soon  after  an- 
nounces the  formation  of  pus  in  the  glands  or  cellular  tissue.  The 
early  treatment  should  be  cleansing  and  disinfection  of  the  wound 
to  prevent  the  further  absorption  of  septic  fluids;  rest;  active  purga- 
tion; local  applications  of  lead  and  opium  lotions,  or  inunctions  of 
mercurial  ointment;  wrapping  the  limb  in  cotton,  the  limb  mean- 
1  C.  H.  Moore;  T.  Billroth. 


INJURIES   OF   THE    CIRCULATORY  SYSTEM.         219 

time  being  elevated  and  wrapped  so  as  to  maintain  an  even  tem- 
perature. If  pus  forms  it  must  be  evaeuated  early ;  if  it  is  in  a 
•rland,  and  healing  does  not  progress  satisfactorily,  use  hot,  moist 
applications,  lest  the  poison  again  extend  from  the  gland. 

VI.    ARTERY  AND  VEIN. 

Wounds  may  penetrate  an  artery  and  adjacent  vein,  or  the  lesion 
of  the  two  vessels  may  occur  spontaneously,  an<l  lead  to  an  admix- 
ture of  the  two  curri'iits,  creating  a  form  of  annurism. 

Arterio-venous  aneurism  is  (lescribi;d  as  of  two  kinds:  (1)  An- 
eurismal  varix,   when   the  two  vessels    are   so  __^  ~~2;^' 

united  at  the  scat  of  lesion  that  the  arterial  ''''M[T''^v^^u..n.Ml\ilLvL^ 
current  passes  directly  into  the  vein  without  the  ^^^-  ^^*^- 

intervention  of  a  sac  (Fig.  166);  (2)  varicose  aneurism,  when  there 
is  a  sac  interposed  between  the  artery  and  vein 
(Fig.  167).     The   symptoms   are  well  defined; 
the  vein  pulsates,   enlarges,  becomes  tortuous,    "tilmi^iTiin; 
and    has   a  fusiform    shape;    there   is   often    a  Fig.  167. 

harsh  rasping  sound  on  the  proximal  side ;  the  mass  is  soft  and  com- 
pressible. The  tendency  of  the  tumor  is  to  an  arrest  of  growth. 
At  an  early  period  it  may  often  be  cured  by  pressure  simultaneously 
made  on  the  main  artery  and  on  the  orifice  of  conununication  by 
two  persons,  one  pressing  lightly  on  the  point  at  which  the  arterial 
stream  enters  the  tumor,  with  sufficient  force  to  suspend  the  coo- 
ing murmur,  the  other  compressing  the  artery  at  some  convenient 
spot  above  the  tumor.^  If  the  tumor  enlarges  and  radical  treat- 
ment is  necessary,  the  ligature  should  be  applied  to  the  vessels  at 
the  seat  of  lesion. ^  An  anaesthetic  being  given,  apply  the  elastic 
bandage  to  the  limb;  make  a  long  and  free  incision  over  the  tumor; 
lay  open  the  sac  to  its  full  extent,  and  remove  the  blood  ;  pass  a 
probe  through  the  orifice  into  the  sac  and  lay  it  open;  now  find  the 
opening  into  the  artery,  and  apply  a  ligature  to  that  vessel  above 
and  below  the  lesion  ;  ^  the  artery  may  be  tied  outside  of  the  sac  in 
small  tumors;  if  necessary,  the  vein  may  also  be  ligated.^  Both  the 
artery  and  vein  have  been  successfully  tied  above  and  below  the 
tumor.^ 
1  T.  Holmes.      2  w.  H.  Van  Buren.     3  p.  h.  Hamilton.      *  T.  Annaudale. 


220  OPERATH'E  SURGERY. 


CHAPTER    XXII. 

DISEASES  OF  THE   CIRCULATORY  SYSTEM  AND   SPECIAL 
OPERATIONS. 

I.     THE    HEART. 

1.  Inflammation  of  the  serous  pericardium,  if  of  traumatic  origin, 
may  result  in  the  formation  of  pus  in  its  cavity,  or,  if  idiopathic, 
may  terminate  in  an  accumulation  of  serum.  Whatever  may  be  the 
nature  of  the  distending  fluid,  if  it  leads  to  great  embarrassment  of 
the  heart's  action  and  the  respiration,  and  all  the  usual  remedies 
have  failed  to  give  relief,  removal  by  the  aspirator  or  trocar  and 
canula  may  with  proper  precautions  be  undertaken. 

H.    THE  ARTERIES. 

1.  Arterial  thrombosis  is  the  formation  of  blood-clot,  or  throm- 
bus, in  an  artery,  and  is  caused  by  retardation  of  the  blood-current, 
or  irregularities  on  the  inner  wall  of  the  vessel,  which  increase  the 
friction  between  it  and  the  passing  blood;  they  are  Liminated  when 
formed  by  an  intermittent,  gradual,  and  long-continued  coagulation, 
as  in  aneurism,  and  non-laminated  when  they  originate  in  sudden 
coagulation  of  an  isolated  mass  of  blood,  as  after  ligature  of  an  ar- 
tery. The  clot  may  organize  and  become  a  member  of  the  series  of 
vascular  connective  tissues,  or  it  may  soften,  giving  rise  to  abscess 
or  embolism.^ 

2.  Cirsoid  aneurism  is  the  dilatation  and  lengthening  of  an  ar- 
tery, givinir  it  the  appearance  of  varicosity;  it  may  appear  over  the 
occiput,  vertex,  temples,  or  in  the  extremities;  it  usually  lies  just  under 
the  skin,  and  is  readily  recognized  by  the  tortuous  pulsating  artery  or 
arleries.2  The  treatment  should  be  directed  to  the  prevention  of  the 
further  enlargement  of  the  artery  by  elevating  the  part  as  much  as 
possible,  douches  of  cold  water  followed  by  supporting  appliances, 
as  elastic  bandages,  laced  stockings  when  the  lower  extremity  is  af- 
fected. When  the  tumor  is  inconvenient,  or  from  other  causes  it  is 
necessary  to  undertake  a  radical  cure,  the  ligature  of  the  trunk  ar- 
tery leading  to  it,  though  an  exceedinrrly  uncertain  measure,  is  per- 
haps the  best,  the  dilated  vessel  itself  being  too  much  altered  in 
structure  to  bear  the  ligature  with  safety.' 

3.  Aneurism  by  anastomosis  differs  from  the  preceding  only  in 
1  E.  Rindfleisch.  2  T.  Billroth.  3  T.  Holmes. 


DISEASES   OF   THE   CIRCCLATORY  SYSTEM.      221 

the  larger  niiiiibcr  of  arteries  involved  and  the  final  implication  of 
capillaries  and  veins.  They  are  large,  irregular,  lobulated,  pulsating 
masses,  in  which  a  considerable  bruit  can  often  be  heard,  and  nu- 
merous large  vessels  can  be  traced  into  them  on  all  sides;  the  capil- 
laries share  in  the  enlargement,  and  the  veins  thus  receive  the  pulsa- 
tion; as  the  arteries  enlarge,  their  coats  become  thin,  so  that  it  is 
impossible  to  distinguish  between  the  arteries  and  veins  around  the 
tumor;  their  favorite  seats  are  the  scalp  near  the  ear  and  the  lip.^ 
Excise  the  mass,  if  small  and  favorably  situated,  as  on  the  lip,  cut- 
ting wide  of  the  growth ;  "^  apply  the  ligature  subcutaneously,  as  in 
na?vus,  when  the  tissues  admit;  apply  a  ligature  to  the  trunk  of  the 
main  artery  Avlun  the  growth  is  favorably  Iocate<l,  as  to  the  external 
carotid  when  the  disease  is  in  the  temporal  artery,  to  the  common 
carotid  when  the  orbit  is  the  seat  of  the  disease;  electro-puncture 
should  be  employed  in  severe  cases,  especially  when  deeply  situated;  * 
coagulating  agents,  as  perchloride  of  iron,  may  be  injected,  care 
being  taken  to  prevent  the  escape  of  coagula  by  accurate  pressure 
around  the  growth;  amputate  when  the  disease  affects  seriously  the 
bones  of  the  extremity. 

4.  Atheroma*  consists  in  a  chronic  intlammation  of  the  inner  coat 
of  the  artery;  the  predisposing  causes  are  advanced  age,  alcoholic 
stimulants,  gouty  diathesis,  and  the  localizing  cause,  mechanical  irri- 
tation of  the  impact  of  the  blood  on  i)oints  of  curvature  and  bifurca- 
tion of  the  artery;  the  change  consists  in  a  thickening  of  the  mem- 
brane it^elf,  a  proliferation  in  and  from  the  connective  tissue  of  the 
intima,  causing  an  increase  of  its  bulk,  and  culminating  in  an  in- 
llamniatory  overgrowth.  Retrograde  tissue-metamorphosis  now  be- 
gins, which  may  terminate  in  fatty  degenerations  of  the  cells,  com- 
bined with  solution  of  the  intercellular  substance,  and  the  formation 
of  an  atheromatous  abscess;  or  the  intercellular  substance  may  be- 
come impregnated  with  earthy  salts,  a  calcification,  and  form  plates 
of  vari;il)le  size  and  form.  The  result  of  these  changes  is  diminu- 
tion of  the  calibre  of  the  vessel,  which  leads'  to  diiinnislied  force  of 
the  circulation  beyond  the  lesion,  and  increased  force  on  the  proxi- 
mal side.  Two  effects  may  follow:  (1)  lessened  nutrition,  and  even 
gangrene  of  the  extremity  supplied  by  the  obstructed  artery;  or, 
(2)  yielding  of  the  vessel,  causing  aneurism.  The  treatment  is  lim- 
ited to  the  effects  of  the  disease.  If  gangj'ene  occur,  amputation 
must  be  performed  only  when  the  line  of  demarcation  is  well  estab- 
lished; if  the  operation  is  undertaken  too  early,  reamputation  may 
be  required,  owing  to  the  extension  of  the  disease.  Aneurism  re- 
quires special  treatment. 

5.  Aneurism  occurs  when  the  coats  of  an  artery,  weakened  by 
1  T.  Ilulmes.  ^  Heine.  ^  J.  Spence.  *  E.  Rindfleisch ;  K.  Moxon. 


222  OPERATIVE  SURGERY. 

atheroma  or  calcification,  yield  at  the  point  of  greatest  pressure  of 
the  blood-current,  and  give  rise  to  a  tumor.  The  shape  and  size 
which  it  assumes  depend  upon  the  number  of  coats  involved,  the 
location  of  the  lesion,  and  the  surrounding  tissues.  It  may  be  in- 
vested by  all  of  the  coats  of  the  artery,  by  one  or  more  coats,  or 
the  coats  may  have  all  ruptured,  and  the  investing  capsule  may 
be  the  connective  tissue;  or,  finally,  the  blood  may  be  extra vasated 
among  the  tissues,  due  to  the  rupture  of  the  coats  from  atheroma,  or 
overstrain,  and  generally  at  arterial  curves  or  subdivisions.  The 
diagnostic  signs  are:  (1)  A  tumor  in  the  course  of  an  artery;  (2)  ex- 
pansive pulsation,  synchronous  Avith  the  heart;  (3)  a  bruit;  (4)  ces- 
sation of  pulsation  and  diminution  of  tumor  on  compressing  the 
artery  on  the  proximal  side.  There  are  many  sources  of  error  in 
these  signs,  and  hence  they  must  be  carefully  studied  as  a  group; 
if  doubt  remains,  puncture  with  a  hypodermic  syringe,  or  the  needle 
of  an  aspirator,  and  examine  the  contents. 

The  various  methods  of  treatment  aim  at  the  consolidation  of  the 
blood  in  the  tumor,  and  obliteration  by  absorption  or  organization  of 
its  contents.  This  may  be  effected  by  oi)erations  upon  the  tumor  and 
upon  the  arteries.  The  operations  upon  the  tumor  are  designed  to 
diminish  the  force  of  the  circulation,  or  interrupt  it  altogether,  in 
order  to  effect  coagulation  of  its  fluid  contents. 

1.  Manipulation  1  is  practiced  to  displace  a  clot  which,  escaping  from  the 
cavity  into  the  artery,  is  carried  to  a  lower  point  where  it  lodges,  and  plugs  the 
artery,  and  leads  to  a  set-back  and  interruption  of  the  current  through  the 
aneurism.  It  has  been  successfully  employed  in  popliteal,  femoral,  carotid, 
and  subclavian  aneurism,  and  is,  undoubtedly,  a  justifiable  measure  in  tumors 
which  cannot  be  operated  on  without  very  great  danger,  and  are  not  near  to 
bursting,  and  in  which  there  is  evidence  of  blood-clot. ^  Fatal  results  have  fol- 
lowed this  operation  when  practiced  on  aneurisms  of  the  neck  from  embolism  of 
the  brain. 3  Place  the  flat  end  of  the  thumb  on  the  prominence  of  the  tumor, 
and  press  until  the  fluid  contents  escape,  and  the  upper  surface  of  the  aneurism 
is  pressed  against  the  lower;  now  give  a  rubbing  motion  to  the  thumb  so  as  to 
cause  a  friction  of  surfaces  within  the  flattened  mass. 

2.  Injection  of  coagulation  agents  has  proved  successful;  but  as  this 
method  is  always  liable  to  cause  dangerous  inflammation,  gangrene,  embolism, 
it  is  not  justifiable  where  compression  can  be  used.*  The  agent  preferred  is  a 
neutral  solution  of  perchloride  of  iron,  twent}'  minims  strength. 5  Compress  the 
artery  above  and  below  the  tumor  so  as  to  completely  arrest  the  circulation; 
introduce  the  needle  of  the  hypodermic  syringe  perpendicularly  to  the  tumor 
until  the  extremity  is  within  the  cavit\'  of  the  aneurism,  as  will  appear  by  the 
escape  of  arterial  blood;  the  canula,  containing  fifteen  to  twenty  drops  of  the 
fluid,  is  screwed  on  to  the  needle;  now  inject  drop  by  drop,  occasionally  changing 
the  position  of  the  extremit}'  of  the  needle  to  form  new  centres  of  coagulation; 
when  the  tumor  has  become  sufficiently  firm,  draw  the  piston  to  suck  up  any 

1  Sir  W.  Fergusson.  2  x.  Holmes.  ^  F.  Esmarch. 

*  Marsacci.  6  Valletta. 


DISEASES  OF  THE   CIRCULATORY  SYSTEM.     223 

free  acid  wliich  would  irritate  the  soft  tissues,  and  carefully  withdraw  the  instru- 
ment ;  coiitiiiiic  oi)inpre>si(in  on  the  cardiac  side  for  an  hour  or  n)ore. 

3.  The  elastic  bandage  has  been  successfully  employed,  the  object  being  to 
completely  conlnji  the  circulation  of  the  limb  and  tumor  for  a  time.  Apjily  the 
elastic  bandage  from  the  extremity  upward  above  the  tumor,  but  lightly  over 
the  aneurism;  apply  the  elastic  tubing  around  the  limb  over  the  highest  turn 
of  tlie  bandage,  and  remove  the  bandage;  the  limb  is  now  pallid  and  the  tumor 
pulseless;  after  fifty  minutes,  aj)|ily  compression  to  the  main  trunk,  and  remove 
the  tubing;  continue  pressure,  if  necessary,  in  an  iijtermittent  manner  for  a  day 
or  two,  when  the  cure  will  be  found  complete. ^ 

4.  Flexion-  has  been  successful  in  aneurism  at  the  bend  of  the  elbow, 
knee,  anil  hip,  and  is  indicated  in  small  aneurisms,  so  situated  that  the  pulsa- 
tion and  bruit  are  suspended  by  bending  the  joint:  it  need  not  be  extreme  nor 
painful,  nor  neeil  the  limb  be  bandaged  or  confined  in  any  way  in  many  cases, 
as  voluntary  flexion,  the  patient  being  allowed  to  change  the  position  of  the 
limb  slightly,  will  sometimes  succeed  when  forced  flexion  would  not  be  tolerated; 
as  flexion  acts  by  retarding  the  blood-stream  and  displacing  dot,  pressure  n)ay 
be  combined  in  the  treatment;  forced  flexion  may  cause  ru|)ture  of  the  sac* 
IJandage  the  limb  from  the  extremity  nearly  to  tlie  joint,  then  flex  the  limb 
firmly  and  turn  the  roller  around  the  part  above,  thus  fixing  the  forearm  or 
leg  in  a  fle.xed  position. 

5.  Foreign  bodies  have  been  introduced  into  the  cavity'  of  the  aneurism  for 
the  purpose  of  iiulucing  coagulation  by  whipping  the  blood;  the  cases  selected 
were  most  unfavorable,  and  all  were  fatal,  but  not  from  the  effect  of  the  opera- 
tion. Iron  wire,'*  horse  hair,^  carbolized  catgut,''  are  the  agents  which  have 
been  used;  they  were  introduced  through  a  fine  canula. 

a.  Electrolysis  is  designed  to  secure  a  gradual  deposit  of  the  layers  of 
fibrin,  and  has  proved  successful  in  forty-eight  out  of  ninety  cases,"  for  the 
most  part  of  the  extremities  ;  abdominal  and  thoracic  aneurisms  have  rarely 
been  benefited ;  in  the  latter  case,  if  the  disease  tends  certainly  to  death  and  other 
methods  have  failed,  electro-puncture  would  be  justified.*  Give  an  aniesthetic; 
begin  with  one  or  two  cells;  introduce  into  the  aneurism  two  or  three  needles 
connected  with  the  negative  pole,  while  a  sponge  electrode  connected  with  the 
positive  pole  is  applied  to  the  adjacent  surface;  the  length  of  the  application 
may  be  five  to  forty-five  minutes;  from  one  to  four  or  five  operations  are  usually 
sufficient.'' 

Operations  upon  the  arteries  are  perforined  for  the  purpose  of  ar- 
resting the  flow  of  blood  into  the  aneurism,  and  thus  promoting  co- 
agulation. 

1.  Xiigation  of  the  arterial  trunk  has  long  been  the  approved  method  of  ob- 
structing the  circulation  in  an  aneurism.  The  ligature  has  generally  been  some 
irritating,  indestructible  material,  as  silk,  which,  in  its  application,  ruptured  the 
internal  coats,  and  then  by  slow  degrees  divided  the  external  coat,  and  was  cast 
off  from  the  w(uind.  The  cure  of  the  divided  artery  was  effected  by  the  organ- 
ization of  a  clot,  and  the  final  repair  of  the  cut  ends;  but  this  process  is  al- 
ways lialile  to  be  interrupted;  the  clot  may  not  organize  and  the  cut  ends  of  the 
artery  may  not  repair,  owing  to  the  inflammation  whiili  the  ligature  creates. 
This  result  is  followed  by  hivmorrhage  from  the  wound,  always  a  dangerous 

1  W.  Reid.        2  E.  Hart.        8  T.  Holmes.        *  C.  H.  Moore.       5  K.  j.  Levis. 
«  Murray.        7  A.  M.  Hamilton.       8  H.  I.  Bowditch.       »  Beard  &  Rockwell. 


224  OPERATIVE  SURGERY. 

complication.  These  dangers  are  ver}'  materially  diminished  by  the  use  of  an 
uiiirritating  ligature,  as  silver  or  iron  wire,  which  may  remain  long  in  the 
wound  without  causing  inflammation.  But  the  most  perfect  results  are  ob- 
tained when  an  uiiirritating  and  absorbable  ligature  is  used,  as  carbolized  cat- 
gut. The  ligature  need  not  be  so  tightly  applied  as  to  sever  the  coats  of  the 
artery,  and  the  wound  may  at  once  be  pernutnently  closed.  The  course  of  re- 
pair consi^ts  in  the  union  of  the  exteinal  wound  without  suppuration,  the  union 
of  the  opposed  surfaces  of  the  internal  coat  of  the  artery,  the  replacement  of 
the  old  ligature  bj'  a  new  ligature  of  living  tissue  which  strengthens  the  artery 
at  the  point  of  ligation.  It  follows  that  such  a  ligature  may  be  applied  where 
silk  would  ordinarily  prove  fatal,  as  in  the  vicinity  of  large  trunks,  and  where 
a  resulting  intiammation  would  dangerously  complicate  the  operation,  as  in  prox- 
imity with  serous  cavities.  The  only  defect  in  the  method  of  applying  absorb- 
able ligatures  is  the  liability  of  their  absorption  before  the  cure  is  completed; 
but  this  has  been  remedied  b}'  preparing  the  catgut  so  that  it  will  remain  firmly 
applied  for  a  sutHciently  long  time  and  then  undergo  absorption  without  irrita- 
tion, 'i'he  rule,  therefore,  shouUl  be  to  select  a  ligature  which  is  unirritating, 
and  will  be  absorbed,  and  to  apply  it  with  antiseptic  dressings.  But  if  such  a 
ligature  is  not  at  hand,  the  silk  should  be  carbolized,  and  applied  antiseptically. 
The  several  points  of  ligation  are  as  follows:  (1)  On  the  cardiac  side,  near  the 
tumor,!  or  near  the  first  collateral  branch,  above  the  aneurism;'^  the  latter  point 
is  alwaj's  to  be  preferred  when  the  artery  is  readily  accessible,  as  the  femoral, 
for  popliteal  aneurism;  (2)  on  the  distal  side  ^  when  the  artery  cannot  safely 
be  reached  on  the  cardiac  side,  as  the  subclavian  or  common  carotid  in  innomi- 
nate aneurism;  (3)  At  its  entrance  into,  and  exit  from,  the  aneurism,  the  old 
operation,*  as  in  carotid  aneurism  at  the  base  of  the  neck,  or  traumatic  aneu- 
risms. 

2.  Compression  consists  in  the  application  of  pressure  to  the  artery,  on  the 
cardiac  side,  with  a  view  to  cause  stagnation  of  a  mass  of  blood  in  the  aneu- 
rism until  it  coagulates.  This  method  is  capable  of  curing  the  majority  of 
surgical  aneurisms,  and  when  it  fails,  in  no  marked  manner  militates  against 
the  adoption  of  other  measures. °  Pressure  may  be  digital  or  instrumental;  the 
former,  when  successful,  is  more  rapid  and  less  painful,  and  should  be  preferred 
if  all  the  conditions  are  favorable.  To  be  successful,  pressure  must  be  regular, 
efficient,   and  equable. ^ 

Commence  the  treatment  by  preparing  the  patient  with  several  days  of  rest 
and  low  diet  to  reduce  the  circulation;  select  three  or  four  reliable  assistants, 
who  must  be  employed  for  four  or  five  hours  consecutively,  each  in  rotation 
applying  pressure  for  ten  minutes  at  a  time;  the  pressure  must  be  steady  and 
equal  by  the  finger  or  thumb  placed  directly  over  the  vessel,  with  just  suf- 
ficient force  to  arrest  the  flow  of  blood  and  no  more;^  if  the  patient  becomes 
restive,  give  anodynes;  or  it  may  be  necessary  to  intermit  to  give  the  patient 
rest.  The  pressure  of  the  fingers  may  be  reinforced  by  placing  a  weight,  as 
a  bag  of  shot,  upon  the  ends.  The  cure  may  be  verj'  rapid,  even  occurring 
in  one  and  a  half,  two  and  a  half,  and  three  hours,''  or  it  may  be  prolonged; 
pressure  should  not  be  given  up  unless  after  several  days  no  impression  is 
made,  or  the  surface  ulcerates.  Instrimiental  compression  ma}'  be  made  in  a 
variety  of  ways,  but  in  all  cases  the  point  used  for  pressure  should,  as  far  as 
possible,  be  small,  like  the  finger  ends,  in  order  to  make  accurate  pressure  on 
the  artery  and  avoid  compression  of  the  vein.  A  simple  appliance  is  a  bag 
1  Anel.  2  J.  Hunter.        3  Brasdor.        4  j.  Syme.        5  T.  Bryant. 

6  T.  Holmes.  •  J.  Knight. 


DISEASES   OF   THE   CIRCULATORY  SYSTEM.      225 


sac  of  sand  or  small  shot,  made  tapering  at  one  end,  and  suspended  by  an  elastic 
band;  tourniquet  pads  may  be  adapted  to  various  forms  of  apparatus  so  as  to 
make  (iressiire  at  a  single  point  {¥\g.  1G8), 
or  at  several  points  allowing  intermittent 
])ressure. 

3.  Acupressure  can  be  practiced  with 
safety  upon  arierifs  which  are  so  much  dis- 
eased that  I  hey  aie  too  brittle  and  friable  to 
bear  I  lie  strain  of  a  ligature;  in  cases  of  aneu- 
rism where  the  artery  is  diseased  for  some  dis- 
tance above  llie  sack,  the  vessel  may  be  closed 
by  an  acupressure-needle  at  a  point  where  it 
would  be  inexpedient  to  apply  a  ligature; 
thus,  an  aneurism  of  the  lower  femoral  may 

be  treated  by  acupressure  at  the  upper  portion  of  the  femoral,  whereas,  if 
treated  by  deligation,  the  ligature  would  have  to  be  placed  upon  the  external 
iliac  artery,  a  much  more  serious  operation. 1  Pass  the  needle  under  the  artery 
and  make  a  tigiire  of  8  with  the  thread. 

4.  Constriction-  is  made  by  the  artery  constrictor  (Fig.  169);  expose  the 
artery  at  the  point  for  constriction,  and  apply  the  constrictor  (Fig-  170)  as  di- 


FiG.  168. 


E-;= 


oc^ 


Fig.  169. 

Fig.  170. 

rected  (p.  25);  the  internal  coats  being  ruptured,  remove  the  instrument  and 
accurately'  close  the  wound;  a  clot  forms,  the  current  of  blood  is  permanently 
interrupted,  and  the  consolidation  of  the  aneurism  takes  place. 


III.    THE  VEINS. 

1.  Venous  thrombosis  is  due  to  the  same  conditions  which  caus^ 
thrombus  of  an  artery,  namely,  retardation  of  the  circulation,  or 
irrogiilarities  in  the  coats  of  the  vessels.  More  frequently  they  are 
caused  by  acute  inflammation  of  cellular  tissues,  especially  under 
fascia,  tense  skin,  or  boiie.^  The  thrombus  forminp;  at  one  point 
often  extends  by  the  deposition  of  fibrin  to  other  branches  until  a 
largje  number,  or  a  plexus  of  veins,  is  filled.  The  clot  may  be  re- 
absorbed, or  organized  into  connective  tissue,  or  suppurate,  forming 
an  abscess,  or  undergo  disintegration,  giving  rise  to  embolism.^  The 
treatment  is  absolute  rest,  with  applications  of  ice  ;  friction  with 
mercurial  ointment  to  prevent  embolism;  early  evacuation  of  purulent 
collections.-' 

2.  Varices  are  veins  in  a  state  of  permanent  dilatation.  Veins  in 
certain  localities,  as  in  the  plexuses  of  the  true  pelvis  and  its  outlet, 


1  J.  C.  Hutchison. 


15 


2  S.  F.  Spier. 


8  T.  Billroth. 


226  OPERATIVE  SURGERY. 

and  in  the  superficies  of  the  leg,  undergo  permanent  dilatation, 
causino-  varix,  jjhlebectaj^y.  This  change  is  the  result  of  a  local 
rise  in  the  blood-pressure;  the  disorder  is  never  restricted  to  a  sin- 
o-le  and  very  marked  dilatation  of  a  vein,  but  always  involves  the 
moderate  dilatation  of  an  entire  j)lexus,  or  of  all  of  the  branches  of 
a  single  trunk;  the  distention  begins  just  above  the  valves,  -which, 
having  to  support  a  greater  weight  than  usual,  become  incompetent, 
and  the  vein  is  stretched  longitudinally;  the  fixed  condition  of  both 
ends  of  the  vein  compels  the  elongated  vessel  to  bend,  forming  zig- 
zags, or  become  spirally  twisted.^  The  tendency  to  varices  is  indi- 
vidual, or  inherited;  hence  the  ordinary  causes  act  u2)on  existing 
predispositions.^  Dilatation  may  affect  alike  both  the  suj)erficial  and 
deep  veins ;  ^  in  the  former  case  the  disease  is  ajjparent,  in  the  latter 
it  is  recognized  by  the  enlargement  of  parts,  the  unusual  weight, 
achinf,  and  sense  of  weariness.  In  general,  varices  are  merely 
causes  of  discomfort  and  inconvenience;  but  they  may  create  disa- 
bilities so  serious  as  to  necessitate  operations  designed  for  their 
radical  cure.  The  general  plan  of  treatment  is  as  follows :  Remove 
the  causes  of  local  blood-pressure;  support  the  distended  veins  and 
restore  their  tonicity;  operate  only  upon  such  varices  as  cause  serious 
inconvenience  or  permanently  disable  the  patient.  The  special 
treatment  must  vary  with  the  particular  class  of  veins  affected,  their 
condition,  and  the  causes  which  created  and  maintain  the  varicose 
state. 

The  veins  which  more  frequently  become  varicose  and  require 
radical  treatment  by  o[)erations  are  as  follows:  — 

1.  The  internal  saphena  vein,  varicose,  forms  soft  nodular 
masses,  or  tortuous  elevations  of  the  skin  on  the  anterior  and  inner 
aspect  of  the  leg;  the  disease  may  involve  a  few  branches  or  the 
entire  plexus  and  the  trunk  above  the  knee.  It  occurs  more  often 
in  persons  who  stand  much;  in  women  Avho  have  borne  many  chil- 
dren; and  in  those  who  have  undue  pressure  upon  some  part  of  the 
main  trunk.  Palliative  treatment,  in  the  forui  of  the  elastic  stock- 
ing, can  be  most  satisfactorily  employed.  Operations  are  very  rarely 
required;  those  most  approved  are  as  follows:  (1)  Acupressure; 
raise  the  vein  so  as  not  to  puncture  it,  pass  two  pins  under  it  an 
inch  npart,  and  twist  a  figureof-8  silk  ligature  around  the  ])ins,  or  use 
India-rubber,  or  wire;  now  pass  a  tenotome  under  the  included  vein 
and  divide  it  subcutaneously;  support  the  limb  with  a  bandage;  re- 
move the  pins  in  three  to  five  days;  excision  should  be  delayed 
several  days;*  (2)  injections  of  coagulating  fluids;  use  persulphate 
of  iron  with  hypodermic  syringe  thus :  apply  a  compress  and  roller  on 
ithe  vein  above,  the  patient  first  standing  until  the  vein  is  well  dis- 

1  E.  Kiiidfleisdi.  2  t.  Billroth.  3  Verneuil.  4  H.  Lee. 


DISEASES  OF  THE   CIRCULATORY  SYSTEM.     227 

tended;  fill  the  syringe  and  then  force  out  a  drop  or  two  to  expel 
the  air,  point in<^  upwards;  select  several  of  the  most  jirominent  nod- 
ules and  inject  into  each  three  or  four  drops;  apply  adhesive  plaster 
over  the  ])unctures;  retain  the  compress  over  the  vein  two  or  three 
days  and  enjoin  perfect  rest. 

2.  The  heemorrhoidal  veius,  varicose,  constitute  Iiicniorrhoids; 
they  have  their  orij^in  in  con:^'estion  of  the  venous  radical^^  in  the 
lax  submucous  tissue  of  the  rectum  close  to  the  anus;  mucous  ca- 
tarrh and  overgrowth  of  the  mucous  follicles  follow;  at  a  later 
stage  the  phlehcctasy  proceeds  to  the  development  of  large  plexuses 
of  varicose  veins  which  pu.^h  the  mucous  membrane  before  them  and 
form  a  ring  of  transverse  ruga;  round  the  anal  aperture;  the  dilata- 
tion finally  concentrates  at  one  or  more  points  of  these  rugae,  which 
develop  into  rounded  protuberances,  and  ultimately  into  fungoid  tu- 
mors of  considerable  size  ;  the  chief  part  of  the  texture  of  a  lucmor- 
rhoid  is  spongy,  being  atrophied  connective  tissue,  caused  bv  the 
pressure  of  the  distended  veins  kept  up  by  the  persistently  increased 
tension  in  their  interior;  infiammation  often  occurs  about  tliese  venous 
plexuses,  resulting  in  induration  or  suppuration,  and  blood  may  co- 
agulate in  their  interior.^  Veins  may  rupture  into  the  connective 
tissue  around  the  anus,  and  by  subsequent  infiammation  and  con- 
densation of  connective  tissue  give  rise  to  tumors  of  various  size, 
color,  and  density,  external  piles.  In  general,  patients  c>omplain 
of  fullness  and  weight  in  the  rectum,  pain  in  the  loins  and  thighs, 
bleeding  after  defecation.  Every  case  should  be  thoroughly  exam- 
ined before  the  plan  of  treatment  is  settled.  Place  the  patient  on 
the  side,  on  the  edge  of  a  sofa,  with  the  knees  drawn  up;  separate 
the  nates  gently;  external  piles  will  appear  as  tabs,  or  bluish  more 
or  less  inflamed  masses  covered  by  skin  ;  internal  piles  may  protrude 
from  the  anus  as  large  grape-like  tumors,  often  very  sensitive,  or, 
if  not  protruding,  the  finger  well-oiled,  introduced  into  the  rectum, 
will  detect  the  growths. 

In  early  sta'.'cs  luemorrhoids  may  be  cured  by  the  removal  of  those 
conditions  which  cause  congestion  of  the  veins  of  the  rectum,  and 
the  free  use  of  cold  water  to  the  anus  when  the  bowels  move.  If 
the  piles  are  inflamed,  direct  rest  in  the  recumbent  j)osiiion;  hot 
or  cold  applications,  as  may  be  most  agreeable;  mild  cathartics,  as 
the  following:  mag.  sulphate,  mag.  carb.,  sulphuris  precipitati,  sacch. 
lactis,  aa  5^^-  !  p"lv.  anisi,  3ii-;  ^I-;  take  one  or  two  teaspoonfuls  at 
bed-time.-  If  external  piles  suppurate,  apply  anodyne  poultices; 
when  the  inflammation  subsides  use  astringents,  as  lead  water,  oint. 
nut-galls.  If  internal  piles  become  prolapsed  and  painful,  with  fin- 
gers well  oiled,  or  with  a  cloth  wet  with  cold  water,  reduce  them  by 
1  E.  Rindfleisch.  a  G.  T.  Elliot. 


228 


OPERATIVE  SURGERY. 


gentle  pressure,  the  patient  reclining  with  the  hips  raised,  or  resting 
on  his  knees  and  elbows. 

External  piles  should  be  removed  by  excision:  place  the  patient 
on  the  side  with  the  thighs  flexed ;  subdue  sensation  by  local  anses- 
thesia ;  seize  the  pile  with  firm  forceps  and  excis^e  with  curved  scis- 
sors by  incisions  radiating  from  the  anus.  Internal  piles  may  be 
removed  by  ligature  or  cautery.  Strangulation  by  the  ligature  is 
the  safest,  surest,  and  most  manageable  procedure; ^  give  a  full 
dose  of  castor  oil  twelve  hours  before  the  operation;  secure  the 
protrusion  of  the  piles  as  far  as  possible  by  the  efforts  of  the  patient, 
after  an  enema  of  warm  water,  straining  over  a  vessel  containing 
hot  water;  place  the  patient  on  the  side  and  separate  widely  the 
buttocks;  if  an  ansesthetic  is  used,  the  position  with  the  upper  part 
of  the  body  prone,  the  hips  elevated,  and  the  thighs  flexed  on  the 
abdomen  is  preferable,  and  in  this  case  commence  the  operation  by 
forcible  dilatation  of  the  sphincter  ani,  by  which  the  interior  of  the 
lower  part  of  the  rectum  is  fully  exposed.^  Seize  the  tumor  with 
forceps  or  a  tenaculum ;  avoid  the  skin  or  make  a  light  incision 
around  its  base  where  the  covering  is  integument ;  transfix  with 
a  curved  needle  armed  with  a 
double  ligature  of  stout  silk  (Fig. 
170);  divide  the  ligature  at  the 
eye  of  the  needle  and  tie  each 
half  around  its  portion  of  the 
tumor  with  such  firmness  as  to 
thoroughly  strangulate  the  part 
(Fig.  171);  cut  off  the  ends  of 
Fig.  170.  the  ligature  and  half  of  the  protruding  mass  of 

the  tumor,  if  it  is  very  large;  ligate  all  the  liEemorrhoidal  tumors  in 
the  same  manner,  and  return  the  mass  within  the  sphincter. 

The  cautery,  galvanic  or  iron,  is  preferred  by  many  surgeons;  prepare  the 
patient  as  for  ligation;  on  seizing  the  pile  with  forceps  apply  a  clamp  (Fig.  172) 

on  its  base;  the  blades  of  the  clamp, 
the  surfaces  of  which  are  faced  with 
ivory  to  prevent  the  communication 
of  heat  to  sensitive  parts,  close  per- 
„       ,_^  -  fectiv  parallel  bv  means  of  a  screw 

so  as  to  compress  the  mass  equally; 
cut  off  with  scissors  half  of  each  mass,  dry  the  surface,  and  apply  the  cautery 
at  a  white  heat  until  the  remaining  portion  is  burned  to  an  eschar  down  to 
the  clamp;  remove  the  clamp  carefully,  and  with  well-oiled  fingers  return  the 
eschars  within  the  sphincter;  apply  cold  to  prevent  infiannnation  and  give 
opiate  suppositories  or  morphine  to  relieve  pain  and  quiet  the  bowels;  confine 
the  patient  to  bed  with  a  light  diet;  at  the  end  of  four  or  five  days  move  the 
bowels  witli  oil. 

1  W.  H.  Van  Buren.  2  h.  Smith. 


Fig.  171. 


DISEASES   OF   THE   CIRCULATORY  SYSTEM.      229 

If  the  tumor  is  small,  sessile,  strawberry-like  in  appearance,  fre- 
quently emitting  bright  red  blood,  it  is  composed  larj^ely  of  congested 
mucous  iiienil)rane,  and  may  be  treated  with  nitric  acid.  Prepare 
the  patient  as  for  ligature;  while  the  lucniorrhoid  is  protruded,  wipe 
the  surface  with  lint  and  touch  it  with  the  end  of  a  flat  piece  of  wood 
dip|)ed  in  nitric  acid;  smear  the  parts  well  with  oil,  and  return  the 
whole  within  the  anus.  It  is  not  necessary  to  confine  the  patient  to 
bed ;  if  hieniorriiage  occur,  examine  the  part,  and  apply  a  styptic  to 
the  bleeding  sin-facc. 

3.  The  urethral  veins  of  the  female  become  varicose,  and  appear 
as  small  vascular  tumors  of  the  meatus  urinarius;^  they  may  be  sin- 
gle or  multiple,  pedunculated  or  sessile;  their  most  frequent  site  is 
the  floor  of  the  meatus  at  its  extremity,  but  they  may  extend  deepily. 
The  more  marked  symptoms  are  proneness  to  bleed,  great  sensitive- 
ness, liability  to  become  extruded  and  inflamed,  pain  during  mic- 
turition. An  examination,  which  should  always  be  made  when  a 
patient  complains  of  pain  in  urination,  with  occasional  bleeding,  re- 
veals the  nature  of  the  disease.  The  ligature  and  caustic  are  the 
only  effective  agents.  Administer  an  anaesthetic  and  place  the  pa- 
tient in  the  position  for  lithotomy;  if  the  ligature  is  used,  transfix 
the  mass  from  behind  forwards  with  a  fine  tenaculum  and  apply  the 
thread  beneath  the  instrument  so  as  to  inclose  the  base  of  the  tu- 
mor; if  caustic  is  preferred,  it  must  be  boldly  used;  the  actual  cau- 
tery, especially  the  galvanic,  is  most  manageable.  Chromic  acid 
may  be  used  as  follows  :  surround  the  growths  with  cotton  wool 
soaked  in  solution  of  carbonate  of  soda;  make  a  swab  of  cotton  wool 
on  a  stick,  with  which  apply  the  acid  solution;  repeat  in  five  or  six 


4.  The  spermatic  veins,  when  varicose,  constitute  varicocele; 
these  veins  are  subject  to  turgescence,  the  chief  factor  in  its  produc- 
tion being  ungratified  sexual  desire,  or  abuse  of  the  sexual  organs, 
by  which  the  veins  are  kept  constantly  engorged;^  dilatation,  serious 
enough  to  constitute  a  disease,  is  an  exaggeration  of  this  condition; 
it  occurs  in  early  manhood,  on  the  left  side,  rarely  on  the  right;  the 
vessels  are  elongated,  the  valves  broken  down,  and  the  walls  thick- 
ened and  affected  with  fatty  atrophy ;  the  mass  fills  up  one  side  of 
the  scrotum,  is  of  a  pyriform  shape,  and  has  the  feeling  of  a  bunch 
of  earth  worms;  in  the  recumbent  position  the  tumor  disappears, 
proving  that  it  is  not  hydrocele,  and  if  a  finger  is  pressed  on  the 
external  ring,  when  the  patient  rises,  the  tumor  will  return,  showing 
that  it  is  not  hernia.  The  slighter  grades  are  cured  by  the  removal 
of  the  conditions  inducing  congestion  of  the  veins,  and  the  free  use 
of  cold  water;  the  severe  forms  may  be  palliated  by  the  use  of  the 

1  J.  Ilutchiusou.  2  X.  W.  Kllis.  8  Van  Burcu  and  Keves. 


230 


OPERATIVE  SURGERY. 


suspension  apparatus,  and  a  compress  or  truss  so  placed  over  the 
external  ring  as  to  prevent  the  distention  of  the  veins  by  exertion. 
As  all  procedures  for  the  radical  cure  are  more  or  less  dangerous, 
an  operation  should  be  undertaken  only  in  those  cases  where  the  pa- 
tient is  kept  in  a  state  of  constant  unrest,  and  worried  into  bad 
health  by  morbidly  dwelling  on  his  troubles;  or,  in  neuralgia  with 
liabilitv  to  atrophy  of  testicle,  or  when  the  suspensory  bandage  fails, 
or  the  patient  is  not  satisfied  with  it.^  When  operative  ])rocedures 
are  required  two  methods  are  advocated:  (1.)  Excision  of  the  scro- 
tum is  regarded  as  the  only  method  which  offers  a  fair  prospect  of 
relief  without  serious  accompanying  risks ;  it  is  curative  only  in  the 
sense  of  preventing  further  disease,  arresting  atrophy  of  the  testis, 
and  usually  relieving  pain,  and  the  result  is  nearly  uniformly  satis- 
factory.^ Place  the  patient  in  the  recumbent  position,  the  testis  be- 
inof  raised  to  the  external  ring  by  an  assistant;  draw  a  sufficient 
portion  of  the  relaxed  scrotum  between  the  fingers;  excise  with  the 
knife  or  large  scissors  and  tie  all  bleeding  arteries ;  bring  the  edges 
of  the  incised  skin  together  by  raising  the  lower  portion  towards  the 
upper,  and  apply  the  requisite  number  of  sutures.^  (2.)  Oblitera- 
tion of  the  large  veins  by  subcutaneous  ligature  is  as  follows  :  ^  — 

(o.)  With  the  left  thumb  and  index-finger  separate  the  vas  defer- 
ens, which  feels  hard  and  cordlike,  from  the  veins;  carry  a  needle 
armed  with  a  double  ligature  behind  the  veins  and  leave  it  in  place; 
now  drop  the  veins  and  grasp  only  the  skin  and  through  the  same 
ori6ces,  but  in  the  reverse  direction,  carry  a  second  loop  in  front  of 
the  veins;  the  bundle  of  veins  (Fig. 
173)  is  included  between  the  two  loops; 
pass  the  free  extremities  of  each  thread 
through  the  loops  of  the  other,  and 
tighten  them  (Fig.  174),  thus  effectually 
strangulating  the  veins  under  the  skin ; 
fasten  the  extremities  by  tying  over  a  small  roll  or  compress.  Sub- 
cutaneous section  may  be  performed  as  follows:* 
(/;.)  Pass  a  needle  between  the  vas  deferens 
and  the  veins  at  two  points,  separated  one 
inch,  apply  a  ligature  over  each  needle  suffi- 
ciently firm  to  stop  all  circulation  in  the  veins; 
two  days  after  divide  subcutaneously  the  veins 
which  feel  like  soft  cords  between  the  two  pins;  two  days  later 
withdraw  the  pins;  Aviihin  the  next  three  or  four  days  the  cure  will 
be  complete  by  the  consolidation  of  the  veins. 

5.  Venous  neevi,  cavernous  angiomata,^  consist  chiefly  of  dis- 


FiG.  173. 


Fig.  174. 


1  Van  Buren  and  Keyes. 
i  H.  Lee. 


^  Sir  A.  Cooper. 
5  T.  Billroth. 


3  M.  Ricord. 


DISEASES  OF  THE   CIRCULATORY  SYSTEM.     231 

tended  vt'iii.*,  in  a  white,  firm,  tou'^h  network,  liavia.^  an  indistinct 
bouniiary;  or  a  sort  of  capsule;  these  tumors  are  rarely  conirinital, 
but  generally  appear  in  cliildhood  or  youtli ;  their  seat  is  chiefly  in 
the  subcutaneous  cellular  tissue,  more  frccjuently  in  the  face;  they 
often  occur  in  large  numbers,  but  in  such  a  way  tliat  a  certain  vas- 
cular district  is  to  be  regarded  as  the  seat  of  disease,  as  the  face, 
arm,  foot,  or  leg;  they  cause  weakness  of  muscles,  some  pain,  and 
disfigurement;  they  may  attain  considerable  size  and  prove  danger- 
ous, especially  by  their  destruction  of  bone;  they  are  recognized  by 
fluctuation,  want  of  pulsation,  compressibility,  and  swelling  on  forced 
expiration.  The  tumor  must  be  destroyed  by  (1)  excision,  when 
the  growth  is  large,  the  line  of  incision  being  quite  external  to  the 
capsule;  (2)  injection  of  persulphate  of  iron,  in  small  quantities, 
when  the  tumor  is  small,  and  not  amenable  to  other  remedies,  as  on 
the  face,  great  care  being  taken  to  compress  the  vessels  around  the 
tumor  to  prevent  the  escape  of  the  fluid  into  the  general  circulation. 

III.     THE    CAI'ILLARIES. 

The  capillaries  may  form  vascular  or  erectile   tumors,  consisting 
almost  exclusively  of  vessels  held  together  by  connective  tissues. 

The  plexiform  angioma,  telangiectasis,  cutaneous  naevus,  is  com- 
posed entirely  of  dilated  and  tortuous  capillaries  and  anastomosing 
vessels,  and  occurs  almost  exclusively  in  the  cutis ;  they  may  be  of  a 
dark  cherry,  or  a  steel-blue  color,  according  as  the  superficial  or 
deep-seated  vessels  of  the  cutis  are  involved ;  they  are  sometimes  as 
large  as  a  pin's-head,  and  again  as  a  henip.seed;  some  are  moderately 
thick,  others  scarcely  rise  above  the  level  of  the  skin;  as  a  rule, 
this  proliferation  of  vessels  does  not  extend  beyond  the  subcutaneous 
cellular  tissue,  their  growth  is  always  slow  and  painless;*  they  fre- 
quently not  only  cease  to  enlarge,  but  undergo  a  gradual  contraction 
and  obliteration;  hence  the  propriety  of  treating  them  at  first  with 
mild  remedies,  as  pressure,  applications  of  collodion,  vaccination.  If 
more  radical  measures  become  necessary,  inject  persulphate  of  iron, 
using  precautions  by  pressure  around  the  growth  ..-;^-. 
to  prevent  the  entrance  of  coagula  into  the  cir-  .••;•' 
culation;  or  pass  red-hot  needles  under  it  at  ^ 
several  points  and  secure  a  slough.  Strangu-  '^ 
lation   of   the    mass    by  subcutaneous   ligatuif,  ^'-^'^ 

when  the  growth  is  accessible,  is  adapted  to  the 
larger  najvi,  and  may  be  applied  in  many  ways, 
as  follows:  (1)  The  single  ligature;  strong  whip  ^'*"'-  ^~^' 

cord  (Fig.  175),  is  carried  around  the  tumor  by  entering  it  at  one 
point  and  carrying  it  as  far  as  possible  round  the  l»a>;e.  then  emerwin" 
1  T.  Billroth.  2  x.  Holmes. 


232 


OPERATIVE  SURGERY. 


Fig.  176. 
round  the  half 


(Fie 


Fig.  177. 
176).      For  a  large  nae- 


and  reentering  at  the  same  puncture  and  carried  around  another  por- 
tion, until  it  reaches  the  point  of  first  entrance,  where  the  two  ends 
are  firmly  tied;  (2)  or,  if  the  growth  is  too 
large,  the  ligature  may  be  carried,  double, 
under  the 
tumor,  and 
then  each 
section  may 
be  carried 
as  before,  and  tied 
vus  the  following  knot  may  be 
made  :  ^  Pass  the  needle  under 
the  centre  of  the  tumor  (Fig. 
177),  divide  one  thread   near    "^\___^^_,a8!^«rTX. 


the  needle;  pass  the  other  end 
of  the  ligature  into  the  needle's 
eye;  now  enter  the  needle  at  a  Fig.  179. 

quarter  of  the  circumference  and  pass  it  under  the 
base  at  right  angles  to  its  former  direction  (Fig. 
177;)  before  tying  the  ends  make  a  lunated  in- 
cision between  each  puncture  into  which  the  lig- 
W^^i^  ature   sinks;   finally,  tie  the   opposed   ends  (Fig. 
179). 

If  the  tumor  is  elongated  in  form  the  ligature 
may  be  applied  as  follows  (Fig.  180):  Pass  a 
double  ligature  under  its  base  from  side  to  side; 
color  the  end  of  one  ligature  white  and  the  other 
black;  leave  each  loop  long,  the  whole  ligature 
being  of  great  length;  divide  the  white  loops  on 
one  side  and  the  blnck  on  the  other,  and  tie  the 
pairs  of  white  and  black  strings  tightly;  the  skin 


Fig.  178 


is  destroyed  by  this  method.^ 


CHAPTER  XXIII. 


GENERAL   OPERATIONS  ON    THE   CIRCULATORY  SYSTEM. 

I.     THE  HE.\RT. 

The  only  general  operation  on  the  heart  and  pericardium  is  un- 
dertaken for  the  relief  of  dropsy.  In  order  to  perform  any  opera- 
tion upon  this  organ  it  is  important  to  be  able  to  define  its  normal 
position. 

1  Sh-  W.  Fergusson.  2  T.  Holmes. 


OPERATIONS   ON  THE   CIRCULATORY  SYSTEM.     233 

That  part  of  the  heart  which  lies  immediately  behind  the  wall  of  the  chest, 
and  is  not  covered  by  lung,  is  sulliciently  defined  for  all  practical  purposes  by 
a  circle  two  inches  in  diameter  round  a  point  midway  between  the  nipple  and 
the  end  of  sternum;  the  apex  pulsates  between  the  fifth  and  sixth  ribs,  two 
inches  below  the  ni[)ple,  and  one  inch  to  its  sternal  side,  this  point  varying 
sli{;htly  witli  the  position  of  the  body,  and  with  inspiration  and  expiration. i 

Paracentesis  of  the  pericardium  is  practiced  as  follows:  The 
most  prominent  point  beinjr  carefully  determined,  select  the  left  fifth 
intercostal  space,  from  two  fifths  of  an  inch  to  two  inches  from  the 
sternum,  accordinir  to  the  prominence  of  the  sac;^  make  an  incision 
a  Httle  more  than  an  inch  long  parallel  to  the  ribs  in  the  centre  of 
the  space  commencing  about  two  fifths  of  an  inch  to  the  left  of  the 
sternum;  carefully  divide  the  layers  of  muscle  until  an  elastic  dila- 
tation is  felt  which  resists  under  pressure  with  an  indistinct  impulse 
of  the  apex  of  the  heart ;  make  a  slight  puncture  and  introduce  a 
small  trocar  ^  or  the  aspirating  needle. 

II.     THE  ARTERIES. 
The  general  operations  upon  the  arteries  are  arteriotomy  and  iiga- 
tion. 

The  arteries  possess  considerable  strength  and  a  high  degree  of  elasticity, 
being  both  extensible  and  retractile  in  width  and  length;  they  are  inclosed  in 
a  sheath  of  connective  tissue  and  have  three  independent  coats,  namely,  inter- 
nal, middle,  and  external;  the  internal  coat  consists  of  epithelium  and  elastic 
tissue;  the  middle  of  muscular  fibres  disposed  circularly  round  the  vessel,  and 
the  external  of  elastic  and  connective  tissue;  arteries  are  accompanied  by  one 
or  more  veins,  and  nerves.* 

Arteriotomy,  very  rarely  practiced,  is  performed  to  secure  sud- 
den loss  of  blood  and  thus  make  a  profound  impression  on  the  sys- 
tem or  relieve  sudden  congestion.  The  temporal  artery  is  prefeiTed, 
and  the  anterior  branch  selected.  Incise  its  coats  obliquely  with  a 
sharp-pointed  lancet  or  bistoury,  and  when  suflScient  blood  has 
flowed,  divide  it  completely,  and  apply  a  compress  and  bandage. 

The  ligation  of  an  artery  is  still  the  more  conmion  method  of 
radically  treating  aneurisms.  Before  the  operation  the  following 
facts  should  receive  due  consideration:  — 

1.  The  instruments  rerpiired  are  a  scal|)el,  forceps,  aneurismal 
nee<lle,  ligature,  director,  and  spatulas.  The  common  scalpel  is 
best  adapted  to  the  dissection,  and  the  broad  extremity  of  the  han- 
dle can  be  used  to  advantage  in  separating  layers  of  fascia,  and 
parts  where  the  cutting  edge  is  not  ilesiralile;  the  dissecting  forceps 
should  have  accurately  fitting  teeth,  and  not  be  liable  to  open  at  the 
extremity  when  firmly  closed  ;  a  pair  of  small  forceps  may  also  be 
required.  The  aneurism  needle  is  a  curved  blunt  instrument,  with 
1  L.  Holden.        ^  Roger;  Dieulafoy.      8  T.  c.  Albutt.       *  Quain's  Anatomy. 


234 


OPERATIVE  SURGERY. 


an  eye  near  the  extremity,  and  firmly  fixed  in  a  handle  (Fig.  182). 
When  used,  the  extremity  is  gently  insinuated  under  the  VL-ssel,  and 
as  it  appears  upon  the  opposite  side,  the  loop  of  the  ligature  is  seized 
with  the  forceps,  or  a  hook,  and  one  end  heing 
drawn  through,  it  is  held  as  the  instrument  is 
witlidravvn  carrying  the  otlier  end,  and  thus 
leaving  the  ligature  under  the  vessel.  A  needle 
well  adapted  to  those  cases  where  the  artery  lies 
deeply  consists  of  the  handle  and  hook  (Fig. 
184),  and  the  blunt  needle  with  two  eyes  (Fig. 
183);  the  needle  is  fitted  to  the  shaft  (Fig.  184) 
by  a  screw ;  when  used,  the  ligatui'e  is  inserted 
into  the  second  eye ;  the  needle  is  then  passed  un- 
der the  artery,  and  as  the  extremity  emerges  upon 
the  opposite  side,  the  blunt  hook  is  inserted 
into  the  eye,  and  the  needle  is  thus  held  until 
the  handle  is  unscrewed,  when  it  is  drawn  thi'ough 
with  the  ligature.  It  is  sometimes  necessary  to 
include  other  tissues  with  the  artery,  when  the 
sharp  pointed  needle  (Fig.  183)  should  be  used. 
The  director  is  used  in  the  dissection  to  raise  the 
fascia  before  its  division ;  it  is  sometimes  passed 
under  the  artery  as  a  guide  to  the  needle.  Two 
spatulas  are  often  required,  with  which  assist- 
ants separate  the  sides  of  the  wound,  and  ex- 
pose the  deep-seated  parts;  pieces  of  flexible  metal  or  wood  may  be 
used  ;  the  ligature  is  generally  of  the  strongest  dent- 
ists' silk,  or  of  silver  wire,  its  size  proportionate  to 
the  size  of  the  vessel;  in  general  a  large  ligature 
irritates  more  than  a  small  one.  and  is  longer  in  sep- 
arating. If  carbolized  catgut  is  used  it  must  not  be 
too  hard,  or  it  will  be  too  stiff  for  tying,  and  will 
even  act  as  a  foreign  body  as  much  as  silk  does,  and 
yet  it  must  be  so  hard  that  after  soaking  in  serum 
for  weeks,  it  will  still  hold  firmly;  old  ligature  is  far 
preferable  to  new  ^ 
2.  The  patient  must  be  placed  upon  a  firm  bed,  or  on  a  table, 
and  the  assistant  administers  the  anaesthetic ;  the  surgeon  takes  his 
])Osition  generally  on  the  outside  of  the  limb  which  is  the  seat  of  the 
operation ;  a  second  assistant  takes  a  position  where  he  can  conmiand 
the  artery  above  if  by  any  accident  it  is  wounded,  or  if  the  artery 
yields  under  the  tightened  ligature;  a  third  uses  the  sponges;  and  a 
fourth  separates  the  wound  with  the  spatulas.     The  steam  or  hand 

1  J.  Lister. 


Fig.  182. 


Fig. 183. 


OPERATIONS   ON  THE   CIRCULATORY  SYSTEM.     235 

sprjiy  ;i]>par;itus  should  be  used  during  the  operation,  or  a  carbolic 
solution  should  be  thoroughly  applied  to  the  wound  after  the  ligature 
is  a[)p]ii'd. 

3.  The  precise  location  of  the   artery  is  determined,  (1)   By  its 
pulsations;  (2)  l)y  given  anatomical  points  in  the  vicinity.     To  ren- 


Fig.  184. 

der  the  former  distinct,  ihe  limb  should  be  placed  in  a  position  fa- 
vorable to  arterial  circulation  ;  to  render  muscles  and  tendons  most 
distinct  the  limb  should  be  forcibly  extended  at  the  comniencenient 
of  the  operation.  When  the  dissection  has  proceeded  so  far  as  to 
reach  the  vicinity  of  the  artery,  the  operator  is  aided  in  detecting 
its  position  by  fle.xing  the  limb  so  as  to  relax  the  muscles  and  tis- 
sues. The  point  of  application  of  the  ligature,  when  it  is  applied  for 
anein-ism,  will  depend  uj)on  the  situation  and  condition  of  the 
aneurism.  It  should  be  applied  (1)  on  the  cardiac  side  at  a  dis- 
tance from  the  tumor,  2  (Fig.  185), ^  when  the 
artery  can  be  tied  with  comparative  ease  and 
safety,  as  the  femoral  for  popliteal  aneurism; 
(2)  on  the  cardiac  side,  near  the  tumor,  1  (Fig. 
185),-  when  the  space  between  the  tumor  and 
important  parts  on  the  proximal  side  is  slight, 
and  the  artery  in  this  space  is  sound,  as  the  ex- 
ternal iliac  for  aneurism  of  the  femoral  near  Pou- 
part's  ligament;  (3)  on  the  distal  side,  3  (Fig. 
185), 8  when  the  proximal  ligature  is  impossible,  as  the  axillarv  for 
subclavian  aneurism;  (4)  on  a  distal  branch,  4  (Fig.  185),*  when 
the  cardiac  and  distal  ligature  of  the  main  trunk  is  impracticable, 
as  in  the  subclavian  for  innominate  aneurism;  (5)  at  the  aneurism, 
the  old  operation,  when  the  tumor  is  so  situated  that  it  is  inadmis- 
sible or  impracticable  to  ligate  the  trunk  on  the  cardiac  or  distal 
side. 

4.  It  is  important,  before  the  first  incision  is  made,  to  ^uard 
ag.ainst  wounding;  superficial  veins.  Their  position  is  readily  defined 
by  compressing  the  parts  above  the  point  of  the  proposed  operation. 

5.  The  operation  involves  several  consecutive  steps:  When  the 
first  incision  is  about  to  be  made,  the  skin  should  be  rendered  tense 
by  the  thumb  and  fingers  of  the  left  hand  applied  on  either  side  of 
the  vessel,  or  the  fingers  applied  at  the  extremity  of  the  proposed 
incision,  parallel  to  its  course  ;  if  the  first  method  is  chosen,  care 

1  J.  IIiMiter.  2  Anel.  *  Brasdor.  ■»  Wardrop. 


236 


OPERATIVE  SURGERY. 


Fig.  186. 


must  be  taken  not  to  make  more  traction  on  one  side  than  on  the 
other.  The  second  method  answers  where  the  skin  is  naturally  tense 
and  but  slight  traction  is  necessary.  Hold  the  scalpel 
in  the  second  or  third  position  (Figs.  27,  28);  make 
the  incision  directly  over  and  parallel  to  the  artery, 
through  the  skin  only  if  the  artery  is  superficial,  but 
also  through  the  cellular  tissues  if  it  is  deep,  its 
length  varying  with  the  depth  of  the  vessel  and  the 
adipose  tissue.  The  incision  is  sometimes  made  in 
the  direction  of  the  fibres  of  the  muscle  covering  the 
arter\',  as  where  the  great  pectoral  overlies  the  axil- 
lary ;  at  other  times  it  should  be  curved,  so  as  to 
raise  a  flap.  The  length  of  the  incision  cannot  be 
prescribed,  but  it  should  always  be  ample.  Pinch 
up  the  fascia  carefully  with  the  forceps  (Fig.  186), 
nick  it  with  the  scalpel  applied  horizontally;  incise 
freely  on  a  director  introduced  beneath.  In  dissect- 
ing among  muscular  structures  enter  the  muscular 
interstices,  and  not  wound  the  substance.  These  inter-muscular 
spaces  are  marked  by  deposits  of  fat,  especially  towards  the  ter- 
minal extremity  of  the  muscles,  and  hence  we  should  commence 
the  separation  of  muscles  as  nearly  as  possible  at  their  terminal  ex- 
tremity.    If   there  is  doubt  as  to  the  line  of  separation,  a  puncture 

will  disclose  adipose  or  muscu- 
lar tissue,  according  to  the  na- 
ture of  the  underlying  struc- 
ture. If  the  dissection  is  made 
through  the  body  of  the  mus- 
cle, the  fibres  separate  more 
readily  in  an  inverse  direction, 
namely,  from  their  origin  to 
their  attachments.  The  mus- 
cles mny  be  separated  with  the 
handle  of  the  scalpel  or  the 
finger  nail.  The  larger  arte- 
FiG.  187.  ries  have  firm  sheaths,   which 

require  to  be  opened  by  dissection;  the  smaller  vessels  have  but 
slight  fibrous  investments,  and  are  readily  exposed  with  the  point  of 
a  director,  or  the  aneurism  needle.  The  sheath  opens  by  jjinching 
up  a  small  portion  with  the  forceps,  and  nicking  it  slightly  with  the 
scalpel ;  into  the  opening  thus  made,  introduce  the  director  or  the 
needle,  and  by  slight  movements  of  its  point,  first  upon  one  side 
and  then  upon  the  other,  separate  the  sheath  completely  around  the 
vessel,  to  an  extent  sufficient  to  allow  simply  the  passage  of  the  lig- 


OPERATIONS  ON  THE   CIRCULATORY  SYSTEM.     237 

ature ;  as  the  extremity  of  tlie  instrument  emerges  on  the  opposite 
side,  with  the  fiiigir  of  the  left  hand,  or  the  thumb  and  fort-finger 
pressed  together,  steady  its  point  as  it  penetrates  the  last  portion  of 
the  sheath.  If  the  artery  is  small  and  very  superficial,  a  director 
may  be  passed  under,  and  along  its  groove,  a  blunt  needle  carrying 
the  ligature.  If  more  deeply  situated,  the  common  aneurism  needle 
(Fig.  182),  or  the  double-eye  needle  (Fig.  183),  shoul<l  be  used. 
The  piiint  of  the  needle  gently  moved  laterally,  aids  materially  in 
separating  the  artery  from  the  sheath.  The  needle  should  be  passed 
from  the  veins;  no  force  should  be  used,  lest  the  instrument  pene- 
trate the  coats  of  the  artery. 

The  ligature  should  be  placed  at  right  angles  with  the  long  axis 
of  a  vessel,  and  the  reef-knot  (Fig.  12)  tied,  unless  there  are  special 
reasons  for  adopting  the  sur- 
geon's knot  (Fig.  11).  The  first 
knot  is  tightened  around  the 
vessels  firmly,  on  either  side  of 
the  ligature,  near  the  artery, 
with  the  index  fingers  carried 
to  the  bottom  of  the  wound 
(Fig.  188).  The  degree  of  con- 
striction varies  with  the  size  of 
the  arteries,  but  it  should  always 
be  sufficient  to  rupture  the  in- 
ternal coats  when  silk  is  used, 


Fig.  188. 


the  sensation  of  which  is  communicated  to  the  fingers.  In  tying  the 
second  knot  care  must  be  taken  not  to  tighten  the  thread  firmly 
until  traction  is  made  on  a  plane  with  the  first  knot,  with  the  fingers 
again  carried  down  to  the  vessel.  The  two  ends  of  the  ligature  are 
tied  together,  and  being  brought  out  of  the  wound  at  its  most  depend- 
ent part,  are  fastened  to  the  external  parts  by  an  adhesive  strap; 
the  edges  of  the  wound  are  brought  together  by  adhesive  straps,  or 
if  the  wound  is  deep  and  gaping,  sutures  are  used. 


ARTERIES  OF  THE  THORAX,  NECK,  AND  HEAD. 

The  general  rules  concerning  the  management  of  aneurisms  and 
the  ligation  of  arteries,  for  their  cure,  in  this  region,  are  as  fol- 
lows : '  — 

Aneurism  of  the  arch  of  the  aorta  is  best  treated  by  rest,  unstimulatinp  diet, 
sedatives,  and  iodide  of  potassium;  the  lipature  is  justifiable  only  when  the  an- 
eurism is  Iielieved  to  imphcate  the  transverse  portion  of  fiie  arch  and  be  e.xtend- 
ing  along  the  course  of  the  carotid  into  the  neck,  in  which  case  the  correspond- 
ing artery,  generally  the  left,  may  be  tied.  In  innominate  aneurism,  when 
medical  treatment  has  failed,  the  tumor  extends,  especially  along  the  trachea, 
1  T.  Holmes. 


238  OPERATIVE  SURGERY. 

as  will  be  proved  by  its  growth  and  the  increasing  dyspnoea;  it  is  justifiable  to 
tie  the  right  carotid,  and  perhaps  also  the  subclavian  artery.  Aneurism  of  the 
common  carotid  low  down  in  the  neck  may  be  treated  with  good  prospect  of 
success  b}' the  distal  ligature. i  Aneurism  near  the  bifurcation,  or  in  one  of  the 
secondary  carotids,  or  their  branches,  mav  be  treated  by  compression  of  the  com- 
mon carotid  at  the  anterior  tubercle  of  the  lifth  cervical  verlebrfle;  if  this  fail  or 
is  impracticable,  and  the  artery  is  easily  accessible,  apply  a  ligature  to  the  trunk. 
In  extreme  cases  an  aneurism  may  form  in  the  carotid  which,  from  its  position 
and  extent,  does  not  admit  of  the  proximal  ligature,  and  from  its  condition  does 
not  warrant  the  distal  ligature;  in  such  a  case  the  operation  of  laying  open  the 
sac  and  tying  the  artery  at  its  entrance  to  the  tumor  has  been  recommended  2 
as  follows:  The  patient  being  under  an  anaesthetic,  with  shoulders  slightly  ele- 
vated, pass  the  knife  into  the  most  prominent  part  of  the  tumor,  and  follow  the 
blade  with  the  forefinger  of  the  left  hand  so  closely  as  to  prevent  the  effusion  of 
blood;  search  with  the  end  of  this  tinger  for  the  opening  in  the  arterj',  and 
when  found,  which  may  be  known  bj'  a  cessation  of  pulsation,  press  firmly; 
now  lay  the  cavity  freely  open,  turn  out  the  clots,  sponge  away  the  blood,  and 
expose  and  ligate  the  artery  first  on  the  cardiac,  and  then  on  the  distal  side. 

1 .  The  innominate  arises  from  the  riglit  suijcrior  portion  of  the 
arch  of  the  aorta,  in  front  of  the  left  carotid,  and  passes  in  an 
oblique  direction,  upwards,  outwards,  and  baclvwards,  to  the  superior 
niargni  of  the  sternal  articulation  of  the  clavicle,  where  it  divides 
into  the  right  subclavian  nnd  right  common  carotid,  being  from  one 
and  a  half  to  two  inches  in  length. 

It  is  in  relation  on  the  right  with  the  pleura,  right  vena  innominata,  and  right 
pneumogastric  nerve;  behind,  with  the  trachea;  on  the  left,  with  the  left  carotid; 
in  front,  above,  with  the  sternum,  and  the  origin  of  the  sterno-hjoid,  and  thj'- 
roid;  below,  with  the  inferior  thyroid  vein  and  left  vena  innominata. 

Place  the  patient  on  the  back,  with  the  shoulders  slightly  raised, 

1  and  face  turned  to  the  oppo- 

)  site    side;    make   an  incision 

/  three  inches  in    length,  just 

y^  above   the  clavicle,  termina- 

/        ,  ting  over  the  trachea,  and,  if 

y/_      -:aa!ll?f^^^feik.  required,    a    second    of    the 

%'".IZ.^- ^^^^W^^^^^y'  same  length,  from  this  point 

^■■-■■/fy/.'.'/.'rrr.T.'"."- ^^^^^^^^^^  along  the  inner  border  of  the 

e - ' ^^^  sterno-mastoid  ;     divide     the 

I  sternal  and  part  of  the  clav- 

\  icular  portion  of  the  sterno- 

„      ^„.  /  mastoid  and  turn   outwards; 

Fig.  189.  '  ,.   .  ,       i  .       . ,         i 

divide   the  sterno-h3'oid   and 

thyroid,  draw  them  inwards,  exposing  the  sheath  of  the  carotid,  par 

vagum,  and  internal  jugular  vein;  now  separate  the  par  vagum  from 

the  carotid:  draw  the  vein  to  the  outside,  and  the  artery  towards  the 

trachea,  and  expose  the  subclavian;  pass  the  needle  from  below  up- 

1  Brasdor.  2  j.  Syme. 


OPERATIONS  ON  THE   CIRCULATORY  SYSTEM.     239 

wards  and  inwards;  care  is  necessary  to  avoid  wounding  the  pleura 
liehiiid. 

Make  an  iiu'isioii  tlirce  inches  in  length,  extending  from  a  point  midway 
between  the  two  sterno-mastoid  muscles,  towards  the  right  shoulder,  iialf  an 
inch  aljove  the  clavicle  (I'ig.  189);  incise  the  skin  and  |)latysma;  then,  on  a  di- 
rector, divide  the  sterno-mastoid,  c,  and  sterno-liyoid  and  thyroid  successively; 
with  the  handle  of  the  knife  the  artery,  (/,  is  isolated,  care  l)eing  taken  to 
avoid  the  pneumogastric  nerve,  b,  the  internal  jugular  vein,  c,  and  the  ])lirenic 
nerve,  a. 

2.  The  subclavian  and  common  carotid  arteries  (Fig.  190) 
may   be   ligated  by  the  fol- 
lowing operation  :  Place  the 
])atient    in   the   position    for 

ligature  of   the  innominate;  « _.. 

make  an  iiK'ision  three  inches  ^  r".""!!^;^™"/^  T'/  7^^3^V  \ 

in  length  through  the  integ-  d  —■^.. — /-I; 

umeiits,  along  the  space  sep-  ^ a^'^'7'^^~^^3A\^ 

aratin<T    the    clavicular   and/ -/■ VmWf 

"  g  \i\>  -■    • 

Sternal    attachments    of  tlie  \^  -.VIL 

sterno-deido  mastoid      mus-      X^ 

cle;  this  interval  is  marked 

by  a  depression    above    the 

clavicle,  at  the  articulation 

f  .1        1-1  If  Fig.  190. 

or  the  clavicle  and  sternum  ; 

fle.\  the  head  ;  slightly  sej)arate  the  internal  portion  of  the  muscle,  «, 
from  the  external,  I) ;  divide  the  sterno-hyoid  and  tliyroid  on  the  di- 
rector; the  innominate,  h:  the  common  carotid,  e:  the  pneumogas- 
tric, (I,  and  its  branch,  the  recurrent  laryngeal;  the  origin  of  tlie 
subclavian,  r/,  and  its  branches,  the  vertebral,  c,  and  inferior  thyroid, 
are  now  readily  seen. 

3.  The  common  carotid  arteries  extend  on  the  right  side  from 
the  innominate,  and  on  the  left  from  the  highest  jioint  of  the  arch  of 
the  aorta,  to  the  upper  border  of  the  thyroid  cartilage ;  the  direction 
is  obliquely  from  before  backwards,  and  from  within  outwards,  along 
the  external  side  of  the  trachea  and  larynx,  in  a  line  drawn  from  the 
sternal  end  of  the  clavicle,  below,  to  a  pcjint  midway  between  the 
mastoid  process  and  angle  of  the  jaw  above.  Its  sheath  is  derived 
from  the  deep  fascia,  and  contains  the  internal  jugular  vein  and  the 
pneumogastric  nerve,  the  vein  being  external,  and  the  nerve  between. 

(a.)  At  the  base  of  the  neck  the  artery  is  deeply  seated,  and  a 
ligature  should  be  applied  at  this  point  only  from  necessity. 

In  front  is  the  platysma,  superficial  and  deep  fasciip,  the  sterno-mastoid, 
sterno-hyoid,  and  sterno  thyroid  muscles;  externally  it  is  in  relation  with  the 
pneumoga-^tric  nerve  and  internal  jugular  vein;  internally  with  the  trachea; 
posteriorly  with  the  longus  colli  and  rectus  aaticu^s  major  muscle;  the  internal 


240  OPERATIVE  SURGERY. 

jugular  of  the  right  side  recedes  from  the  artery,  but  on  the  left  approaches 
and  often  overlaps  it.  The  carotid  tubercle  is  a  guide  to  the  position  of  the  ar- 
terj';!  this  tubercle  is  the  anterior  projection  of  the  transverse  process  of  the 
sixth  cervical  vertebra,  which  is  two  inches  above  the  clavicle,  and  is  a  precise 
guide  to  the  artery  when  the  neck  is  straight;  it  corresponds  in  front  and  a  little 
inside  to  the  artery. 

Operate  as  follows  (Fig.  191)  :  ^  Place  the  patient  on  the  back,  the 


Fig.  191. 

head  extended  and  inclined  to  the  opposite  side ;  recofjnize  the  in- 
terval between  the  two  attachments  of  the  sterno-mastoid  muscle,  and 
make  an  incision  from  the  clavicle,  two  and  a  half  inches,  obliquely, 
along  this  interspace;  divide  the  skin,  platysma,  and  deep  fascia; 
draw  the  internal  portion  of  the  muscle,  c,  inwards,  and  the  external, 

a,  outwards,  by  means  of  spatulas ;  this  exposes  the  internal  jugu- 
lar vein,  bs  and  the  pneuniogastric  nerve,  e,  lying  between  the  vein, 

b,  and  the  artery,  f,  and  the  onio-hyoid  muscle,  d,  crossing  the  upper 
part  of  the  wound ;  open  the  sheath  and  pass  the  needle  from  with- 
out inwards,  carefully  avoidincr  the  internal  jugular  vein  and  par 
vagum  ;  a  finger  pressed  upon  the  vein  at  the  upper  part  of  the 
wound  will  cause  it  to  collapse. 

(6.)  Below  the  omo-hyoid  the  artery  is  much  more  accessible. 

It  is  covered  by  the  integument,  the  platysma,  the  superficial  and  deep  fascite, 
the  sternal  part  of  the  sterno-mastoid,  the  sterno-hyoid  and  thyroid  muscles; 
it  is  crossed  obliquely,  from  within  outwards,  by  the  sterno-mastoid  artery,  also 
by  the  superior  and  middle  thyroid  veins,  and  lower  down  by  the  anterior  jugu- 
lar; on  the  outer  side  are  the  pneuniogastric  nerve  and  internal  jugular  vein, 
and  on  the  inside  are  the  inferior  thyroid  arter}-  and  recurrent  laryngeal  nerve, 
which  separates  it  from  the  trachea  and  thyroid  gland;  the  descendens  noni 
nerve  lies  on  the  sheath  of  the  artery. 

Operate  thus  (Fig.  192)  :  Place  the  patient  on  the  back,  with  the 
head  thrown  back  ;  make  an  incision  three  inches  in  length  along  the 
inner  border  of  the  sterno-mastoid  muscle,  in  the  line  above  given ; 
1  Chassaignac  2  Sedillot. 


OPERATIONS  ON  THE   CIRCULATORY''  SYSTEM.    241 

commencing  on  a  level  with  the  ericoiil  cartilage,  pucce.s^ivcly  divide 
the  skin,  superficial  fascia,  phiiysnia,  and  deep  fascia,  and  expose  the 
inner  l)or(icr  of  the  stcrno-mastoid,  e ;  carefully  avoid  the  sterno-mas- 
toid  artery  and  midiUe  thyroid  vein;  throw  the  licad  forward  and 
draw  the  sterno-mastoid  muscle  outward,  and  the  sterno-liyoid  and 
thyroid  muscles  inwards;  expose  the  anterior  belly  of  the  omo-hyoid 
muscle,  a,  which  should  be  drawn  upwards;  divide  the  deep  fascia; 


Fig.  192. 

expose  the  sluath  of  the  vessel;  open  it  directly  over  the  artery, 
avoiding  carefully  the  descendens  noni,  which  runs  along  the  tracheal 
side;  press  the  pneumogastric  nerve,  d,  and  internal  jugular  vein, 
c,  outward,  and  pass  the  needle  from  without  inwards,  carefully 
isolating  the  vessel  from  tlie  inferior  thyroid  artery,  and  recurrent 
laryngeal  nerve  which  lies  behind  it. 

The  thyroid  body  may  be  so  large  as  ti>  mislead  as  to  the  marj^in  of  the  mus- 
cle, and  then  requires  careful  dissection;  if  the  onio-hyoid  muscle  interferes 
with  the  operation  it  maj'  be  turned  aside,  or  even  divided  by  dissection. 

(c.)  Above  the  omo-hyoid  the  artery  is  still  more  superficial, 
being  covered  only  by  the  skin,  the  two  fascia?,  platysma,  and  the 
border  of  the  sterno-mastoid;  it  is  in  relation  internally  with  the 
larynx  and  pharynx,  and  externally  with  the  pneumogastric  nerve 
and  internal  jugular  vein.  Operate  as  follows:  Place  the  patient 
on  the  back,  the  shoulders  raised,  and  the  liead  turned  to  the  oppo- 
site side;  make  an  incision  from  a  little  l)elow  the  angle  of  tlie  jaw, 
in  the  line  given,  along  the  internal  border  of  the  sterno-mastoid, 
three  inches  in  lengili:  divide  the  integuments,  superficial  fascia, 
and  platysma;  raise  the  deep  fascia  carefully  on  a  director;  avoid 
the  small  imderlying  veins;  flex  the  head  to  relax  the  muscles,  and 
draw  the  wound  apart  by  spatulas;  avoid  the  descendens  noni  nerve 
and  superior  thyroid  arteries,  and  open  the  sheath  over  the  artery  ; 
if  the  internal  jugular  vein  swell  up  into  the  wound,  compress  it  in 
the  upper  and  lower  part  of  the  wound,  and  draw  it  outwards;  pass 
16 


242  OPERATIVE  SURGERY. 

the  ligature  from  without  inwards,  the  point  of  the  needle  being 
kept  close  upon  the  artery,  to  avoid  wounding  the  vein  or  including 
the  pneumogastric  nerve. 

3.  The  external  and  internal  carotids  arise  from  the  common 
trunk  at  the  upper  border  of  the  thyroid  cartilage,  the  external  being 
more  superficial  and  internal  at  their  origins. 

They  occupj'  the  triangle  formed  by  the  stenio-mastoid  beliind,  the  omo-hyoid 
below,  and  the  posterior  belh^  of  the  digastric  and  stylo-hyoid  above;  and 
are  crossed  by  the  hypo-glossal  nerve,  and  the  lingual  and  facial  veins. 

Operate  as  follows:  Make  an  incision  along  the  inner  margin  of 
the  sterno-mastoid,  three  inches  in  length,  from  the  angle  of  the  jaw 
to  the  cricoid  cartilage,  through  the  skin,  platysma,  superficial  and 
deep  fascia  ;  the  internal  margin  of  the  sterno-mastoid  now  appears; 
cautiously  separate  the  cellular  tissue,  and  the  wound  being  drawn 
apart,  the  artery  is  exposed  ;  draw  the  digastric  muscle  and  hj'po- 
glossal  nerve  upwards,  and  the  internal  jugular  outwards;  both  ar- 
teries mny  now  be  ligated  or  either  artery  separately.  The  carbol- 
ized  catgut  ligature  should  be  used  and  the  wound  closed  to  avoid 
all  suppuration. 

4.  The  external  carotid  artery  ascends  from  its  origin  at  first, 
slightly  forwards,  then  backwards,  to  the  space  between  the  condyle 
of  the  lower  jaw  and  the  meatus  auditorius;  above  the  digastric 
the  artery  lies  more  deeply  and  is  crossed  by  the  stylo-hyoid  muscle. 
Operate  thus :  Make  an  incision  from  the  lobe  of  the  ear  to  the  great 
cornii  of  the  hyoid  bone,  along  the  inner  margin  of  the  sterno-mas- 
toid ;  divide  the  skin,  platysma,  and  fascia;  seisarate  the  posterior 
belly  of  the  digastric  and  stylo-hyoid  from  the  parotid  gland,  by 
depressing  the  muscles,  and  the  artery  will  be  exposed. 

5.  The  superior  thyroid  artery  arises  from  the  external  carotid, 
just  below  the  greater  cornu  of  the  hyoid  bone,  and  passes  inwards 
to  the  thyroid  gland  in  a  tortuous  course ;  it  is  at  first  sujierficial, 
lying  in  the  triangle  formed  by  the  sterno-mastoid,  digastric,  and 
omo-hyoid  muscles.  It  is  ligated  thus:  Place  the  head  in  an  extended 
position  ;  make  an  incision  an  inch  and  a  half  along  the  internal  bor- 
der of  the  sterno-mastoid,  the  centre  of  which  corresponds  to  the 
great  cornu  of  the  thyroid  cartilage;  incise  the  skin  and  platysma; 
draw  the  sterno-mastoid  outwards  and  expose  the  omo-hyoid  muscle, 
internal  jugular  vein,  and  primitive  carotid  artery;  the  artery  lies 
between  these  vessels  and  the  lobe  of  the  thyroid  body,  and  is  read- 
ily ligated. 

6.  The  lingual  artery  is  the  second  branch  of  the  external  ca- 
rotid;  it  arises  just  above  the  superior  thyroid,  ascends  to  the  great 

•  cornu  of  the  hyoid  bone,  rinis  parallel  with  it  and  passes  directly  to 
the  base  of  the  tongue  (Fig.  193).     Turn  the  head  to  the  opposite 


OPERATIONS   ON  THE   CIRCULATORY  SYSTEM.     243 

side;  make  an  oblique  incision  an  inch  and  a  half  in  Icni^th,  a  little 
above  the  body  of  the  hyoid  bone,  and  parallel  with  it,  near  the 
median  line,  and  curved  backwards,  outwards,  and  downwards,  par- 
allel with  the  superior  border  of  the  great  cornu  of  the  thyroid  car- 
tilage; divide  the  superficial  parts  and  with  the  finger  recognize  the 
direction  of  the  great  cornu  :  divide  upon  it  the  aponeurosis  which 
covers  the  deep  parts ;  this  exposes  the  digastric  muscle,  the  sub- 
maxillary gland,  hypoglossal  nerve,  and  stylo  hyoid  muscle,  a;  now 
isolate  the  great  cornu  of  the  hyoid  bone,  and  the  fibres  of  the  hyo- 
glossus  muscle,  which  are  attached  at  this  point,  come  into  view; 


Fig.  193. 


divide  this  muscle  at  the  superior  border  of  the  great  cornu ;  draw  it 
upwards  and  backwards,  and  the  artery  is  found  behind  it;  the 
needle  should  pass  from  below  upwards. 

Or,  having  recognized  the  position  of  one  of  the  greater  cornua  of  the  hyoid 
bone,  make  an  incision  about  an  inch  in  length,  parallel  with,  and  about  two 
line«  above  it,  through  the  skin,  cellular  tissue,  and  platysma;  this  incision  will 
expose  the  lower  border  of  the  submaxillar}'  gland,  on  lifting  which  slightly, 
the  shining  tendon  of  the  digastric  will  be  recognized;  less  than  a  line  below 
this  lies  the  hypoglossal  nerve,  and  at  the  distance  of  a  line  below  the  nerve, 
a  transverse  incision  through  the  fibres  of  the  genio-hyo-glossus  muscle  will 
certainly  expose  the  artery,  which,  in  this  situation,  is  accompanied  by  neither 
vein  nor  nerves. l 

7.  The  facial  artery  (Fig.  194)  passes  over  the  lower  jaw,  at  the 
anterior  border  of  the  masseter  muscle,  a;  it  lies  on  the  periosteum, 
and  in  a  groove  which  is  recognized  at  the  junction  of  the  jiosterior 
third  with  the  anterior  two  thirds  of  the  body  of  the  bone;  the  facial 
vein  lies  on  the  outer  side.  The  pulsation  of  the  artery  being  recog- 
nized, make  an  incision  an  inch  in  length,  along  the  course  of  the 
vessel,  as  already  given,  through  the  skin,  fascia,  and  platysma;  the 
wound  being  separated,  and  the  fibrous  tissue  divided,  the  artery,  c, 

1  J.  F.  Malgaigne. 


244 


OPERATIVE  SURGERY. 


is  exposed,  and  the  vein,  &,  and  masseter  muscle,  a,  are  drawn  out- 
wards, and  the  needle  passed. 

8.  The  temporal  artery  (Fig.  194)  runs  upwards  towards  the 
temporal  region  from  its  origin  at  the  condyle  of  the  jaw,  in  front  of 
the  concha;  two  inches  above  the  zygoma  it  divides  into  the  anterior 
and  posterior  branches.  Recognizing  the  position  of  the  artery  by 
its  pulsation,  at  a  point  above  the   zygomatic  arch,  and  in  front  of 


Fig.  194. 


the  ear,  make  an  incision  through  the  skin,  an  inch  in  length;  di- 
vide the  dense  cellular  tissue  on  a  director,  and  the  artery,  a,  will 
be  exposed ;  pass  the  needle  from  behind  forwards  to  avoid  the  tem- 
poral vein,  h,  and  the  auriculo-temporal  nerve. 

9.  The  occipital  artery  arises  from  the  external  carotid,  opposite 
the  facial,  ascends  to  the  space  between  the  transverse  process  of  the 
atlas  and  the  mastoid  process,  and  passes  up  upon  the  occiput. 

(a.)  At  its  origin  the  artery  is  covered  by  the  stylo-hyoid  and  di- 
gastric muscles,  and  the  hypoglossal  nerve  winds  around  it  from 
behind  forwards.  Make  an  incision  along  the  inner  border  of  the 
sterno-mastoid  muscle,  two  inches  in  length,  at  the  angle  formed  by 
this  muscle  and  the  digastric  ;  the  deep  fascia  being  carefully  divided, 
expose  and  isolate  the  artery,  the  nerve  being  carefully  protected. 

(ft.)  Behind  the  mastoid  process  (Fig.  195)  the  artery  passes  up- 
wards, in  a  tortuous  direction,  and  divides  into  branches,  upon  the 
occiput  ;  it  is  covered  by  the  sterno-mastoid  and  splenius  muscles. 
Make  ;in  incision  one  inch  long,  half  an  inch  behind  and  a  little 
beneath  the  mastoid  process,  obliquely  upwards  and  backwards ;  di- 


OPERATIONS   ON  THE   CIRCULATORY  SYSTEM.     245 


:.J....t 


vide  the  skin  and  aponeurosis  of  the  sterno-mastoid  muscle,  c,  as  also 
tlie  splenius  muscle,  through  the  whole  length  of  the  wound  ;  the 
pulsations  of  the  artery,  a,  are 
recognized  by  the  finger  a  little  \ 
above  the  oblique  muscle,  />,  and 
it  is  isolated  from  its  veins. 

10.  The  internal  mammary 
artery  ari-es  from  the  subcla- 
vian, and  descends  behind  the 
clavicle  on  the  inner  surface  of 
the  costal  cartilages  near  the 
sternum. 

The  internal  jugular  and  subcla- 
vian veins  and  the  phrenic  ner\'e 
cross  the  upper  part;  in  the  chest  it 
at  tirst  Hes  on  the  costal  cartilages 
and  intercostal  muscles,  covered  by 
the  pleura  behind ;  but  lower  it  is  cov- 
ered also  bv  the  triangularis  sterni 


Fig.  195. 


muscle;  it  may  be  tied  in  the  second,  third,  or  fourth  intercostal  spaces. 

Make  an  incision  along  the  upper  edge  of  the  rib,  commencing  at 
the  sternum,  in  either  space,  slightly  upwards,  and  outwards,  an 
inch  and  a  half  in  length;  divide  the  skin,  cellular  tissue,  pectorahs 
major  muscle,  fa.«cia,  and  intercostal  muscle  successively ;  a  thin 
layer  of  cellular  tissue  is  expo.<5ed,  which  conceals  the  artery;  j)ass 
the  needle  cautiously  from  within  outwards. 

11.  The  vertebral  artery  arises  from  the  subclavian  artery  in  the 
first  part  of  its  course,  and  passes  directly  along  the  spinal  colimin, 
to  the  foramen  in  the  transverse  process  of  the  sixth  cervical  verte- 
bra, and  along  the  canal  to  the  brain. 

(«.)  Before  entering  the  vertebral  canal  the  artery  passes  behind 
the  internal  jugular  vein  and  inferior  thyroid  artery,  to  the  spine, 
where  it  lies  between  the  scalenus  anticus  and  the  longus  colli,  and 
in  a  line  drawn  from  the  posterior  part  of  the  mastoid  process  to 
the  junction  of  the  internal  fourth  with  the  external  three  fourths  of 
the  clavicle.  Place  the  patient  on  the  back,  the  shoulder  depressed, 
and  the  head  turned  to  the  opposite  side;  make  an  incision  three 
inches  in  length  along  the  inner  border  of  the  sterno-mastoid  mus- 
cle, between  it  and  the  sterno-hyoid,  terminating  at  the  middle  of 
the  upper  extremity  of  the  sternum;  divide  the  skin,  cellular  tissue, 
and  the  aponeurosis  uniting  the  sterno-mastoid  muscle  and  sterno- 
hyoid ;  bring  into  view  the  common  sheath  of  the  carotid,  the  in- 
ternal jugular,  and  the  pneumogastric  nerve;  separate  with  the  finger 
the  cellular  connection  of  the  sheath  with  the  sterno-thyroid  muscle, 
and  finally  with  the  longus  colli;  the  head  is  now  raised,  though  still 


246  OPERATIVE  SURGERY. 

turnt'd  to  the  opposite  side,  and  the  sides  of  the  wound  forcibly  sep- 
arated; divide  tlie  cellular  tissue  at  the  bottom,  and  expose  an  apo- 
neurosis which  passes  from  the  scalenus  anticus  to  the  lougus  colli, 
and  the  anterior  part  of  the  transverse  process  of  the  sixth  cervical 
vertebra,  the  carotid  tubercle;  then  open  the  aponeurosis  an  inch 
below  this  point,  at  the  external  border  of  the  lonj^us  colli  muscle; 
the  artery  is  exposed  very  deeply. 

(6.)  Between  the  atlas  and  axis  the  artery  lies  in  a  triangular  space 
formed  by  the  rectus  posticus  minor  and  superior  and  inferior  oblique 
muscles,  and  is  covered  by  the  rectus  posticus  major  and  com- 
plexus.  Turn  the  head  to  the  opposite  side,  and  incline  it  forwards; 
make  an  incision  two  inches  long  on  the  posterior  edge  of  the  sterno- 
mastoid,  commencing  half  an  inch  above  the  mastoid  process;  make 
a  second  incision,  an  inch  in  length,  from  the  upper  fourth  of  the 
first  incision  backwards  and  obliquely  downwards;  divide  the  skin 
and  cellular  tissue;  then  the  splenius  muscle  with  its  fibrous  expan- 
sion; a  fibrous  layer  now  appears,  which  must  be  cautiously  divided 
to  arrive  at  the  small  arteries  which  lie  beneath  it;  the  edges  of  the 
wound  being  separated,  a  layer  of  fat  appears,  which  is  cautiously 
opened  with  the  finger  or  handle  of  the  scalpel,  and  the  artery  is 
found  within;  the  two  branches  of  the  occipital  artery  are  to  be 
drawn  aside,  as  also  branches  of  the  second  cervical  nerve;  the  ar- 
tery is  isolated,  and  the  needle  passed  from  without  inwards  to 
avoid  the  internal  carotid  artery. 

(c.)  Between  the  atlas  and  occiput  the  anatomical  relations  are  as 
given  above.  The  incisions  are  the  same  as  in  the  last  operation, 
except  that  the  first  commences  one  fourth  of  an  inch  above  the 
mastoid  process;  divide  the  skin,  fascia,  and  splenitis  muscle;  the 
occipital  artery  appears  at  the  upper  angle  of  the  first  wound,  and  is 
held  aside;  divide  the  underlying  aponeurosis,  with  the  cellular  tis- 
sue; separate  the  edges  of  the  wound,  and  in  a  triangle  formed  by 
the  muscles  of  the  part,  the  cellular  tissue,  loaded  with  fat,  covers 
the  artery;  divide  this  and  the  artery  is  exposed;  pass  the  needle  from 
behind  forwards. 

12.  The  inferior  thyroid  artery  is  a  branch  of  the  thyroid  axis; 
it  ascends  the  neck  obliquely,  passing  behind  the  internal  jugular, 
the  pneumogastric  nerve,  the  carotid  artery,  and  omohyoid  muscle, 
to  the  thyroid  body.  It  may  be  ligated  through  the  same  incision  as 
is  made  for  the  ligatui'e  of  the  common  carotid  (Fig.  190). 

ARTERIES    OF    THE    UPPER    LIMB. 

The  following  general  rules  should  guide  in  the  ligation  of  arteries 
of  the  upper  extremity  for  aneurism  :  — 
Aneurism  of  the  subclaviaa  is  usually  fatal  if  left  to  itself,i  and  surgical  treat- 
1  T.  Holmes. 


OPERATIONS   ON  THE   CIRCULATORY  SYSTEM.     247 

Itient  ff»;ni'rally  only  liustens  death;  if  it  occurs  in  tiic  first  or  second  part  of  the 
artery  the  ligature  can  only  be  applied  to  the  innominate,  if  in  the  third  part 
of  the  rijjht,  it  must  he  applied  to  the  first  part  of  the  same  vessel,  but  botli 
operations  have  proved  so  uniformly  fatal  that  tiiey  do  not  warrant  the  trial. 
The  carbolized  eatgut  ligature,  used  with  all  necessary  antiseptic  precautions, 
may  prove  entirely  successful,  as  it  does  not  involve  the  danjjers  of  the  division 
of  the  coats  of  the  artery,  nor  of  suppuration  in  the  wound. i  Axillary  aneu- 
rism should  lirst  be  treated  by  compression  of  the  subclavian  in  its  third  part 
with  the  fingers  or  an  instrument;  if  this  fail,  liyatui'e  of  the  subclavian  in  its 
third  iiart  may  be  resorted  to.  Or,  especially  in  traumatic  aneurism,  the  sac  may 
be  laid  open,  and  the  vessel  found  and  tied,-  |)ressiire  being  made  upon  the  sub- 
clavian over  the  lirst  rib,  an  incision  being-  made  if  necessary  to  reach  the  artery; 
the  relation  of  the  artery  to  the  sac  and  the  nerves  is  very  variable. ^  Aneu- 
risms of  the  vessels  of  the  arm  and  forearm,  if  spontaneous,  are  commonly  asso- 
ciated with  disca.se  of  the  heart  or  general  arterial  degeneration,  and  ought  not 
to  be  actively  treated  ;3  if  traumatic,  they  should  be  laid  open  and  the  vessel  tied 
at  the  point  where  it  is  torn. 

1.  The  subclavian  artery  arises  from  the  iimominate  on  the  right 
side,  and  from  the  arch  of  the  aorta  on  the  left;  it  extends  in  a 
curved  direction  from  its  origin  to  the  lower  border  of  the  first  rib. 

(rt.)  Within  the  scaleni,  on  the  right  sidi-,  the  artery  passes  up- 
wards and  outwards  from  its  origin  from  the  innominate  across  the 
neck  to  the  internal  border  of  the  scalenus  anticus  muscle. 

It  is  very  deeply  situated,  and  lies  upon  the  pleura;  its  anatomical  relations 
are,  in  front,  the  skin,  fascia',  platysma,  origin  of  sterno-mastoid,  sterno-hyoid, 
and  thyroid  muscles ;  it  is  also  crossed  by  the  pneumogastric,  cardiac,  and 
phrenic  nerves,  and  by  the  internal  jugular  and  vertebral  veins;  behind,  it  is 
in  relation  with  the  recurrent  laryngeal  and  .sympathetic  nerves.  On  the 
left  side  the  artery  extends  from  the  left  portion  of  tlie  arch  of  the  aorta  to  the 
scalenus  anticus,  situated  very  deeply,  and  passing  upwards,  almost  vertically; 
in  addition  to  the  anatomical  relations  of  the  light,  the  left  has  in  front  the 
plein-a,  the  lung,  and  the  carotid,  and  internally  the  a>sophagus,  trachea,  and 
thoracic  duct. 

(6.)  The  right  subclavian  is  ligated  thus:  Place  the  patient  on  his 
back,  the  shoulders  raised,  and  the  head  turned  to  the  opposite  side; 
make  two  incisions,  one  parallel  with  the  inner  part  of  tlie  clavicle, 
and  the  other  along  the  miw.v  border  of  the  sterno-mastoid;  pass  a 
director  behind  the  sternal  attachment  of  the  sterno-mastoid,  and 
divide  the  cellular  tissue;  avoid  small  arteries  and  veins  in  this  part, 
and  especially  the  anterior  jugular;  divide  the  sterno-hvoid  and  thy- 
roid muscles  on  a  director;  open  the  deep  fascia  with  the  finger-nail, 
or  end  of  tlie  director,  and  expose  the  internal  jugular,  which  being 
pressed  aside,  pass  the  needle  around  the  artery  from  below  upwards 
to  avoid  the  pleura.  The  left  subclavian  is  ligated  thus:  Place 
the  patient  in  the  position  above  descril)ed;  make  an  incision  three 
and  a  half  inches  long  on  the  inner  edge  of  the  sterno-mastoid,  ter- 
1  J.  Li.-.tu-.  2  J.  Svnie.  3  X.  llclmes. 


248  OPERATIVE  SURGERY. 

minating  at  the  sternum,  thi-ongh  the  skin  and  platysma;  this  is  met 
by  another  incision  along  the  sternal  extremity  of  the  clavicle,  two 
and  a  half  inches;  dissect  the  flap  and  divide  the  sternal  and  half 
the  clavicular  origin  of  the  sterno-mastoid  on  a  director,  and  raise  the 
flap  ;  divide  the  deep  fascia  with  the  handle  of  the  scalpel  and  the  fin- 
gers ;  continue  the  dissection  along  the  outer  side  of  the  deep  jugular 
vein  to  the  inner  edge  of  the  scalenus  anticus  muscle,  half  an  inch 
above  the  rib,  to  avoid  the  thoracic  duct;  the  phrenic  nerve  is  de- 
tected and  avoided,  and  the  fingers  pressed  to  the  bottom  of  the 
wound  discover  the  rib,  and  then  the  artery;  pass  the  needle  from 
below  upwards.! 

(c.)  Between  the  scaleni  the  artery  is  very  short;  it  is  covered 
bv  the  integuments,  platysma,  sterno-mastoid,  and  the  scalenus  an- 
ticus, upon  which  lies  the  phrenic  nerve;  below  is  the  pleura  and 
above  the  brachial  plexus.  The  ligature  has  seldom  been  applied  at 
this  point.  Make  a  deep  incision;  the  tubercle  of  the  rib  being  recog- 
nized, and  the  insertion  of  the  muscle  into  it,  pass  the  director  behind 
it  and  between  the  muscle  and  the  artery,  and  with  a  bistoury,  divide 
the  muscle;  its  retraction  exposes  the  artery,  which  is  readily  ligated; 
pass  the  needle  from  without  inwards.  Or,  divide  the  muscle  from 
without  inwards,  commencing  some  distance  from  the  rib.  The 
phrenic  nerve  is  liable  to  be  divided,  unless  this  proceeding  is 
adopted;  the  internal  mammary  artery  may  be  wounded  if  the  in- 
cision is  too  near  the  rib. 

(J.)  Outside  of  the  scaleni  muscles  (Fig.  196)  the  artery,  h,  passes 
downwards  and  outwards,  lying  in  a  groove  on  the  first  rib. 

It  first  passes  through  the  supra-clavicular  triangle,  and  is  then  covered  only 
by  the  deep  fascia,  the  platysma,  and  skin;  lower  in  its  course  it  is  covered  by 
the  clavicle  and  subclavian  muscle;  the  subclavian  vein,  h,  lies  lower  and  in 
front  of  the  artery,  separated  from  it  by  the  insertion  of  the  scalenus  anticus 
muscle,  c;  the  external  jugular  vein  crosses  in  front  of  the  artery;  the  brachial 
plexus  of  nerves  lies  above  and  behind  the  artery.  The  depth  of  the  artery 
may  vary  from  one  to  three  inches,  according  to  the  depth  of  fat. 

Search  for  the  artery  (Fig.  196)  in  the  supra-clavicular  triangle, 
which  is  bounded  externally  by  the  omo-hyoid  muscle,  internally  by 
the  scalenus  anticus,  and  below  by  the  first  rib;  place  the  patient  on 
his  back,  tlie  shoulders  depressed,  and  the  head  turned  to  the  opposite 
side;  the  skin  over  the  parts  being  drawn  down  upon  the  clavicle, 
make  an  incision  nlong  the  bone,  from  the  anterior  border  of  the  tra- 
pezius to  the  posterior  border  of  the  sterno-mastoid,  e :  divide  the 
platysma  and  superficial  fascia,  care  being  taken  to  draw  the  exter- 
nal jugular  outward,  or,  if  cut,  to  tie  the  ends;  with  the  director  and 
finder  separate  the  cellular  and  fatty  tissue,  and  draw  the  omo-hyoid 
1  J.  K.  Rodgers. 


OPERATIONS   ON  THE    CIRCULATORY  SYSTEM.    249 

inusL-le  aside;  divide  the  deep  fascia  and  the  border  of  the  scalenus, 
d,  being  defined,  pass  the  finger  along  its  margin  down  to  the  first 
rib,  recoiinize  the  tubercle  for  the  attachment  of  that  muscle,  just 
external  to  which  the  artery,  6,  will  be  felt  pulsating;  separate  the 
attachments  of  the  artery  with  the  finger  nail,  and  gently  insinuate 
the  aneurism  needle  beneath  it,  from  before  backwards  and  slightly 


Fig.  196. 

from  within  outwards,  avoiding  the  vein,  c ;  guide  the  point  of  the 
needle  bv  the  end  of  the  finger,  and  prevent  it,  when  it  emerges  upon 
the  opposite  side,  from  engaging  a  branch  of  the  brachial  plexus,  a. 

It  must  be  remembered  that  the  stevno-mastoid  may  have  an  unusually  ex- 
tended insertion  upon  tlie  clavicle,  as  also  the  trapezius,  in  which  case  the  in- 
cision must  involve  the  clavicular  attachments  of  the  former;  the  external 
jui^ular  may  run  so  near  to  the  sterno-mastfiid  as  to  be  involved  in  the  in- 
cision, unless  it  is  carefully  isolated  and  drawn  to  the  outer  or  inner  side;  the 
transverse  cervical  and  supra-scapular  arteries  may  be  met  with  in  tliis  dissec- 
tion, and  if  wounded  should  be  immediately  lii]C''>ted;  the  tubercle  of  the  rib  is 
sometimes  not  well  defined,  in  which  case  the  attachment  of  the  scalenus  to  the 
rib  is  the  y;uide  to  the  artery,  which  is  found  just  posterior  to  its  insertion. 

2.  The  axillary  artery  extends  from  the  lower  border  of  the  first 
rib  to  the  l(jwer  margin  of  the  tendon  of  the  latissimus  dorsi,  or  the 
inferior  l)i)undary  of  the  axilla,  in  a  line  dividing  the  anterior  and 
middle  third  of  the  axilla.     It  may  be  liorated  in  two  places. 

(a.)  Below  the  clavicle  (Fig.  197)  in  its  upper  part,  the  axillary 
artery  is  covered  successively  by  the  insertion  of  the  pectoralis 
minor,  /  .•  higher  up  by  the  pectoralis  major  muscle,  j,  from  which 
it  is  separated  by  a  layer  of  adipose  tissue,  containing  numerous 
small  veins  and  arteries;  and  finallv  by  the  fascise  and  the  skin. 

The  suprascapular  artery,  n,  crosses  the  base  of  the  neck  just  above  the  clav- 
icle; the  a.\illary  vein,  /(,  in  front  and  to  the  inner  side  of  the  artery,  is  not  in 
immediate  contact  with  it;  the  ceplialie  vein  passes  upwards  in  the  interspace 
between  the  deltoid  and  pectoralis  major  muscles,  crosses  the  axillary  arterv 
above  the  pectoralis  minor,  and  empties  into  the  axillary  vein:  the  nerves,  b, 
of  the  brachial  plexus,  c,  lie  behind  and  above;  a  thoracic  branch  often  crosses 
the  artery,  sometimes  in  front,  and  sometimes  behind  it. 


250 


OPERATIVE  SURGERY. 


Place  the  patient  on  his  back,  with  his  shoulders  slightly  raised, 
the  elbow  a  little  separated  from  the  body,  and  the  head  inclined  to 
the  opposite  side  ;  make  an  incision  three  inches  in  length,  three 
quarters  of  an  inch  below  the  clavicle,  and  commencing  about  two 


Fig.  197. 

inches  outside  of  the  sterno-clavicular  articulation,  through  the  skin, 
platysnia,  and  subcutaneous  cellular  tissue;  separate  the  fibres  of 
the  pectoralis  major  gradually  until  the  posterior  investment  of  this 
muscle,  like  an  aponeurosis,  appears;  now  depress  the  shoulder  and 
tear  this  fascia  with  the  point  of  the  director;  press  downwards  and 
outwards  with  the  finger  the  upper-  border  of  the  pectoralis  minor, 


Fig.  198. 


when  the  axillary  vein  is  brought  to  view;  draw  this  gently  forward 
with  a  blunt  hook,  and  behind  it  the  artery  is  found,  with  the  nerves 
of  the  brachial  plexus  still  further  behind  and  above ;  pass  the  needle 
from  within  outwards. 

Or  (Fig.  198),  make  a  transverse  incision  three  inches  in  length,  through  the 
skin  and  platysma,  along  and  upon  the  lower  edge  of  the  clavicle,  three  lingers' 


OPERATIONS   ON  THE    CIRCULATORY  SYSTEM.     251 


breadth  from  the  sternal  extremity  of  that  bone,  and  terminatinf^  an  inch  from 
the  acromion  process  of  tiie  sca[)ula;  make  a  second  incision,  three  inciies  in 
lengtli,  obiiqueiy  througli  tlie  integuments,  over  tlie  deltoid  and  pectoral  mus- 
cles, meeting  the  first  nearly  in  the  centre;  remove  the  cellular  membrane 
and  fat ;  detach  the  clavicul/ir  portion  of  the  pectoralis  major,  r/,  b,  and  remove 
the  cellular  tissue  overlying  the  subclavian  vessels;  the  artery  now  appears  and 
its  pulsations  are  detected  ;  the  pectoralis  minor,  c,  and  the  margin  of  the  del- 
toid, d,  are  brought  to  view,  and  the  artery,  e,  is  isolated  from  the  vein,  a, 
lying  in  front,  and  the  brachial  plexus  behind. 

(J).)   Ik-low  the  i)t'ftoralis  minor,   in   its   lower   half,  the   artery  is 
superfieial,  covered  only  by  the  integuments  and  deep  fascia. 

The   coraco-brachialis   muscle   is   in  h 

contact  with  the  artery,  which  may  be 
found  at  its  internal  anil  jjosterior  bor- 
der; the  brandies  of  the  brachial  plexus 
of  nerves  surround  the  artery,  the  mus- 
culo-cutaneous  lies  along  the  outer  side ; 
the  two  roots  of  the  median  meet  in 
front,  at  the  lower  border  of  the  pecto- 
ralis minor;  the  nerve  then  lies  in  front 
and  to  the  outer  side  of  the  artery;  the 
internal  cutaneous  lies  in  front  and  to 
its  inner  side;  the  ulnar  anil  radial  are 
still  further  within  and  behind ;  the 
axilhiry  vein  is  in  front  of  the  artery 
and  nerves,  which  it  partly  conceals. 

Place  the  patient  (Fig.  199)  on 
the  back,  the  arm  rotated  out- 
wards :  stand   on    the   outside    if 


Fig.  199. 


it  is  the  right  arm,  and  on  the  inner  side  if  the  left,  and  recognizing 
the  inner  border  of  the  coraco-brachialis  muscle,  g,  and  the  pulsa- 
tions, make  an  incision  two  or  three  inches  in  length  in  the  line  in- 
dicated, h,  dividing  only  the  skin  ;  incise  the  fascia  on  a  director; 
with  the  end  of  the  director,  the  axillary  vein,  n,  is  first  pushed  back- 
wards, then  the  brachial  ple.xus;  the  median  nerve,  c,  is  now  recog- 
nized, and  being  brought  forward,  while  the  internal  cutaneous,  e, 
and  ulnar,  d,  are  pushed  backwards,  the  artery,  f,  is  exposed;  sepa- 
rate the  artery  carefully  from  the  vein,  which  is  pushed  backwards, 
and  the  nerves  which  surround  it,  and  pass  the  needle  from  behind 
forwards. 

3.  The  brachial  artery  extends  from  the  lower  margin  of  the  ax- 
illa to  an  inch  Iji'low  the  bend  of  the  elbow,  in  a  line  drawn  from  the 
junction  of  the  anterior  with  the  middle  third  of  the  axilla  to  the 
middle  of  the  bend  of  the  elbow. 

(rt.)  In  the  upper  third,  the  arm  being  extended  as  before,  make 
an  incision  two  and  a  half  inches  in  length  along  the  inner  border  of 
the   coraco-brachialis;  the  artery  is  readily  exposed,   lying  between 


252 


OPERATIVE  SURGERY. 


and  behind  the  median  and  ulnar  nerves,  the  former  to  the  outside, 
and  the  latter  to  the  inside. 

(6.)  In  the  middle  of  the  arm  the  brachial  descends  on  the  inner 
side,  first  of  the  coraco-brachialis,  and  afterwards  of  the  biceps. 

It  is  covered  by  the  fascia  and  integuments,  and  overlapped  slight!}'  by  the 
biceps;  its  sheath  contains  the  two  venaj  comites;  the  internal  cutaneous  nerve 
lies  superficial  to  it;  the  median  is  superficial  to  it  above,  and  rather  to  its  outer 
side;  about  the  middle  of  the  arm,  it  crosses  the  arter^',  and  interiorly  it  is  to  its 
ulnar  side:  the  ulnar  nerve  is  internal  to  the  artery,  and  at  some  distance  from 
it  inferiorl}';  the  spiral  nerve  is  posterior,  and  separates  it  above  from  the 
triceps. 

(Fig.  200.)   The  arm  being  extended  and  carried  at  right  angles  to 
the  body,  and  held  supine,  the  course  of  the  artery  may  be  recog- 
nized, by  its  pulsation;  by  the  internal  margin  of   the  biceps  and 
d   c  coraco-brachialis;     by    the 

median  nerve,  to  the  in- 
ner side  of  which  it  lies; 
by  the  line  above  given. 
Make  an  incision  two  or 
three  inches  in  length, 
along  the  inner  border  of 
the  biceps,  down  to  the 
fascia,  which  incise  on  a 
director;  the  position  of 
the  median  nerve,  b,  is  de- 
tected in  the  wound ;  push 
Fig.  200.  it  aside  with  the  biceps,  d; 

the  artery,  c,  is  found  immediately  behind  and  inside,  accompanied 
by  its  vena;  comites,  a.     The  arm  is  now  flexed,  the  vessel  isolated, 

and   the  ligature  passed  from  without 
inwards. 

If  the  incision  is  made  a  little  too  far  back 
the  ulnar  nerve  is  exposed,  and  is  liable  to 
be  mistaken  for  the  median ;  and  this  error 
may  be  confirmed  by  the  presence  of  the 
vein,  occupying  the  same  relative  position 
as  the  brachial  to  the  median,  which  niaj' 
be  mistaken  for  the  artery.  If  it  is  remem- 
bered that  the  ulnar  nerve  here  passes  down- 
wards and  backwards,  the  error  will  be  rec- 
tified. The  brachial  may  have  a  high  divis- 
ion into  the  radial  and  ulnar;  or  it  may 
have  a  high  division,  and  the  branches  again 
unite  in  the  arm. 


a  he       d  ef 
Fig.  201. 


(c.)  At  the  elbow  the  brachial  artery  lies  in  the  centre  of  a  trian- 


OPERATIONS  ON  THE   CIRCULATORY  SYSTEM.    253 


gular  space,  foriiu-d   by  the  supinator   longus,   externally,   and   the 
pronator  radii  teres,  internally. 

It  rests  on  the  brachialis  anticus;  the  median  nerve  lies  to  the  inner  side  half 
an  inch;  the  tendon  of  the  biceps  lies  on  the  outer  side;  its  coveriiij^s  are  the 
skin,  superficial  fascia,  and  the  median  basilic  vein,  which  is  separated  by  the 
bicipital  fascia. 

The  arm  extended  and  held  in  a  supine  position  (Fig.  201),  make 
an  oblique  incision,  two  inches  and  a  lialf  in  length,  along  the  inter- 
nal edge  of  the  tendon  of  the  biceps,  within  the  median  basilic  vein, 
dividing  only  the  skin;  push  aside  the  vein  and  divide  the  aponeu- 
rosis, which  is  the  deep  fascia,  e,  on  a  director;  the  tendon  of  the 
biceps,  c,  is  now  seen,  and  on  its  inside  the  artery,  a,  with  its  two 
veins,  and  still  farther  in- 
ward the  median  nerve,  h; 
slightly  flex  the  forearm, 
and  pass  the  needle  from 
within  outward,  carefully 
avoiding  the  veins. 

4.  The  radial  artery, 
though  the  smaller  liranch 
of  the  brachial,  lie?  in  the 
direct  course  of  the  latter 
like  a  continuation  ;  its 
course  is  marked  by  a  line 
drawn  from  tlie  centre  of 
the  elbow  to  the  inner  side 
of  the  styloid  process  of  the  radius;  is  superficial  throughout  nearly 
its  entire  course;  the  needle  may  be  passed  in  either  direction. 

(a.)  In  the  upper  third  the  artery  lies  between  the  supinator  longus 
and  the  pronator  radii  teres;  it  has  vena?  comites;  the  radial  nerve 
lies  immediately  on  its  external  side  (Fig.  202).  The  limb  being  ex- 
tended supine,  the  superficial  veins  maile  prominent  bv  pressure  of 
the  thumb  above,  make  an  incision  two  to  three  inches  in  length, 
on  the  internal  border  of  the  supinator  longus,  if  recognized  by  the 
depression,  or  on  a  line  drawn  from  the  middle  of  the  bend  of  the 
elbow  to  the  inner  side  of  the  styloid  process  of  the  radius,  dividing 
the  skin  and  superficial  fascia;  divide  the  deep  fascia  on  a  director; 
flex  the  arm  slightly  to  relax  the  muscles;  the  supinator  lono^us,  a, 
being  drawn  aside,  the  sheath  of  the  artery,  b,  is  exposed;  pass  the 
needle  from  without  inwards. 

(ft.)  In  the  lower  third  of  the  arm  the  artery  is  situated  super- 
ficially, lying  between  the  tendons  of  the  supinator  longus  and  the 
flexor  carpi  radialis ;  it  is  accompanied  by  venae  comites,  and  by  the 
radial    nerve  which  lies  external;   its  pulsation   is  easily  detected 


254 


OPERATIVE  SURGERY. 


Fig.  203. 


(Fig.  203).  The  arm  held  supine,  the  hand  forcibly  extended  to  make 
prominent  the  flexors,  and  the  operator  standinjj  on  the  external 
side  of  the  limb,  make  a  liiiht  incision,  two 
inches  in  length,  from  half  an  inch  above 
the  articulation  of  the  radius,  on  the  exter- 
nal border  of  the  flexor  carpi  radialis,  or  on 
a  line  joining  the  external  with  the  three 
internal  fourths  of  the  arm;  the  deep  fascia, 
a,  is  raised  on  a  director,  exposing  the  ar- 
tery, c,  with  its  two  veins,  b,  and  the  nerve, 
d,  external  and  posterior;  the  needle  may 
be  passed  in  either  direction. 

(c.)  On  the  dorsum  of  the  wrist  (Fig. 
204),  the  artery  passes  in  the  groove  be- 
tween the  upper  extremities  of  the  first  metacarpal  bones;  a  fibrous 
band  separates  it  from  the  tendons  of  the  thumb.  It  may  be  tied, 
just  as  it  is  about  to  form  the  palmar  arch,  or,  as  it  passes  under  the 
extensor  muscle  of  the  thumb,  between  the  extensor  primi  internodii 
and  the  extensor  secundi  internodii  pollicis,  a  little  below  and  pos- 
terior to  the  extremity  of  the  styloid  process  of  the  radius.  At  the 
commencement  of  the  palmar  arch,  make  an  incision  of  an  inch  in 
length  along  the  outer  borders  of  the  extensor  secundi  and  metacarpi 
pollicis,  at  the  angle  formed  by  the  two  first  metacarpal  bones,  care 
^      f)  c  a  being  taken  not  to  wound 

the  superficial  veins  ; 
the  artery  is  readily  ex- 
posed. At  the  higher 
point,  place  the  hand 
between  pronation  and 
supination,  the  thumb 
strongly  abducted  so  as 
to  render  prominent  the 
extensors,  and  make  an 
incision  an  inch  in  length, 
_  between  the  tendons  of 
Fig.  204.  ^Ijg  j^q  extensors,  com- 

mencing at  the  lower  extremity  of  the  radius,  and  in  the  line  of  the 
axis  of  the  first  metacarpal  bone;  make  these  incisions  lightly,  to 
avoid  the  superficial  vein  of  the  thumb;  draw  the  e.xtensor  ossis 
metacarpi  j)ollii-is,  a,  inwards,  and  the  extensor  secundi  internodii 
pollicis,  d,  outwards,  expose  the  artery,  c,  and  its  accompanying 
veins,  b. 

5.  The  ulnar  artery,  the  larger  terminal  division  of  the  brachial, 
passes  to  the  inner  side  of  the  forearm,  at  the  lower  part  of  its  up- 


OPERATIONS  ON  THE   CIRCULATORY  SYSTEM.    2o5 


per  tliird,  continues  alon<;  the  ulnar  side  to  the  wrist,  passes  over 
the  annuhir  ligament,  on  the  outer  side  of  the  pisiform  bone,  and 
terminates  in  the  snperficial  palmar  arch.  Its  course  is  marked  by  a 
line  drawn  from  the  internal  tuberosity  of  the  os  brachii  to  the  ex- 
ternal side  of  the  pisiform  bone. 

(a.)  In  its  upper  third,  the  ulnar  artery,  arising  from  the  brach- 
ial, curves  inwards  deeply  beneath  the  flexor  muscles,  and  passes 
along  the  ulnar  side  of  the  forearm,  between  and  covered  by  the 
Hexor  carpi  ulnaris  and  flexor  sublimis  digitorum;  it  is  accompanied 
by  two  veins,  and  by  the  ulnar  nerve,  which  is  more  superficial  and 
internal,  and  on  the  radial  side  (Fig.  205).  The  forearm  being  su- 
pine, the  hand  strongly  extended  and  inclined  to  the  radial  side, 
make  an  incision  on  the  imaginary  line  given,  three  inches  in  length, 
and  bi-ginning  three  fingers'  breadth 
below  the  internal  condyle  through 
the  skin  and  superficial  fascise,  and 
recognize  tlie  aponeurotic  connection  — 
of  tln!  flexor  carpi  ulnaris  and  flexor 
sublimis,  which  is  of  a  yellowish- 
white  color;  divide  it  on  the  director 
from  below,  where  it  is  the  most  deli- 
cate, carefully  avoiding  the  division 
of  nuiscular  substance;  the  flexor 
sublimis,  a,  is  drawn  outwards,  and 
the  deep  a])oneurosis  exposeil,  under 
which  lies  the  artery;  if  the  vessel  is  not  seen,  press  the  flexor  carpi 
ulnaris,  c,  inwards,  and  expose  the  ulnar  nerve,  b,  a  little  external 
to  which  lies  the  artery,  e,  with  its  two  veins,  d ;  isolate  the  artery 
by  flexing  the  arm  slightly  and  the  hand  strongly;  pass  the  needle 
from  within  outwards. 

(b.)  In  the  lower  third  the  artery  is  covered  by  deep  fascia?,  hav- 
ing upon  its  inner  side  the  flexor  carpi  ul- 
naris and  ulnar  nerve,  and  upon  its  external 
side  the  flexor  sublimis  digitorum.  Place  the 
arm  supine,  and  extend  the  hand  so  as  to 
make  prominent  the  tendon  of  the  flexor 
carpi  ulnaris;  then  along  the  radial  border 
of  this  nuiscle,  a  (Fig.  20G),  or  at  the  union 
of  the  external  four  fifths  of  the  arm  with  the 
internal  fifth,  or  on  a  line  drawn  from  the  in- 
ternal condyle  to  the  i)isiform  bone,  make  an 
incision  about  two  inches  in  length,  through  Fig.  206. 

the  skin,  c,  and  subcutaneous  cellular  tissue,  c;  raise  tiie  deep  fascia 
on  a  director,  or  with  the  forceps,  and  incise  it,  exposing  the  tendon 


256 


OPERATIVE  SURGERY. 


aba 


Fig.  207. 


of  the  flexor  carpi  ulnaris;  this  should  be  pressed  inwards,  and  im- 
mediately behind  it  the  artery,  d,  will  be  found  with  its  two  accom- 
panying veins,  b,  and  the  nerve  upon  the  inside. 

(c.)  At  the  wrist  (Fig.  207)  the  artery  lies  immediately  to  the  radial 

side  of  the  pisiform  bone,  and  is  ac- 
companied by  its  veins,  I),  and  the 
ulnar  nerve,  c,  which  lies  on  its  in- 
ternal and  posterior  aspect.  The 
hand  being  held  back,  make  a  slight- 
ly curved  incision  on  the  radial  side 
of  the  pisiform  bone,  through  the 
skin  and  adipose  tissue,  about  three 
inches  in  length,  its  concavity  look- 
ing inwards;  the  artery,  a,  is  deeply 
seated  in  a  groove,  and  the  dissec- 
tion should  be  continued  along  tlie 
side  of  the  pisiform  bone  until  it  is 
exposed;  the  latter  part  of  the  dissection  will  be  facilitated  by  flex- 
ing the  hand  upon  the  forearm;  pass  the  needle  beneath  from  within 
outwards. 

ARTERIES    OP    THE    LOWER    EXTREMITY. 

Aneurisms  of  the  arteries  of  the  lower  portion  of  the  body,  for 
which  the  ligature  has  been  applied,  now  give  the  following  indica- 
tions as  to  treatment  :^  — 

1.  Abdominal  aneurism,  if  of  the  aorta,  must,  as  a  general  rule,  be  re- 
stricted to  rest  and  medical  measures  only  ;  some  of  the  aneurisms  affecting  the 
lowest  part  of  the  vessel  may  be  under  the  influence  of  pressure  applied  to  the 
artery  as  it  lies  on  the  spine  just  above  the  origin  of  the  mesenteric;  the  artery 
has  been  successful!}'  compressed  where  it  lies  between  the  pillars  of  the  dia- 
phragm; 2  pressure  is  now  a  recognized  surgical  proceeding  very  far  superior  to 
the  ligature  of  the  aorta,  but  is  dangerous  from  protracted  aiiassthesia,  contu- 
sion of  the  viscera,  and  injury  to  the  great  sympathetic  ganglia  and  nerves  ; 
when  employed,  the  patient's  bowels  should  be  freed,  the  walls  relaxed  by 
bending,  full  but  not  deep  anresthesia  produced,  and  the  tourniquet  applied. 

2.  Gluteal  aneurism,  if  traumatic  and  approffching  the  character  of  a  recent 
wound,  should  be  laid  freely  open  and  the  artery  tied,  the  sac  being  plugged 
with  the  finger, 3  or  the  tourniquet  being  applied  to  the  aorta;  compression  of 
the  aorta  or  common  iliac,  galvano-puncture,  or  injection  of  coagulating  fluids, 
are  justifiable  measures;  if  the  aneurism  extend  into  the  pelvis  the  internal 
iliac  may  be  ligated.  Pressure  upon  the  trunk  of  that  artery  might  possibly  be 
effected  by  tln^  fingers,  the  hand  being  introduced  into  the  rectum.* 

3.  Ilio-femoral  aneurism  should  first  be  treated  by  instrumental  pressure, 
under  an  anaisthetic,  of  the  common  iliac  or  the  aorta;  if  pressure  fail,  resort  to 
ligature  of  the  common  iliac.  In  aneurism  of  the  common  femoral  the  external 
iliac  artery  must  be  tied. 

1  T.  Holmes.  ^  Murray.  3  j.  Syme.  *  W.  H.  Van  Buren. 


OPERATIONS   ON   THE   CIRCrLATOIiV  SYSTEM.     2')7 


4.  Popliteal  aneurisms  formini,'  on  tliu  anterior  face  of  tlie  vessel,  known  l>v 
the  distinct  line  of  pulsation  in  the  course  of  the  artery  lying  over  the  tumor, 
are  rarely  cured  by  any  otiier  measure  tlian  the  ligature,  and  this  often  fails, 
rendering  amputation  necessary.  In  treatment  of  the  more  comnion  form,  grow- 
ing from  the  back,  or  partly  from  the  siile  of  the  artery,  marked  by  absence  of 
an_v  distinct  line  of  pulsation,  early  implication  of  the  nerve,  and  swelling  of 
the  foot  and  leg,  digital  or  instrumental  pressure  on  the  femoral  should  be 
made;  if  it  is  very  small,  flexion  may  lirst  be  tried;  if  these  methods  fail,  or  if 
the  aneurism  is  extending,  and  in  all  the  severe  forms  not  demanding  amputa- 
tion, the  ligation  is  the  safest  course. 

1.  The  abdominal  aorta  lies  in  front,  and  a  little  to  the  left  side 
of  the  bodies  of  the  vertehnv,  liavinij;  the  vena  cava  on  its  right  side, 
the  sj'nipathetic  nerve  on  its  left,  and  the  left  lumbar  veins  behind, 
it  may  be  ligated  about  one  ineh  above  its  bifureation.  It  can  be  ex- 
posed and  successfully  ligated  by  the  operation  for  the  common  iliac; 
the  artery  being  separated  from  the  vein  with  the  linger  or  a  direc- 


Fig.  208. 
tor;  pass  the  needle  from  left  to  right.  Or,  make  an  incision  along 
the  linea  alba,  three  inches  in  length,  the  middle  of  it  on  a  level 
with  the  uml)ilicus,  but  a  little  to  the  left;  open  the  peritoneum;  push 
the  intestines  aside;  detect  the  artery  by  its  pulsations,  separate  the 
peritoneal  covering  with  the  finger  nail  on  the  left  side,  carry  the 
finger  under  the  vessel,  and  pass  the  needle  from  left  to  right;  ^  or, 
make  an  incision  from  the  extremity  of  the  tenth  rib  downwards  six 
inches,  curving  backwards  to  within  an  inch  of  the  anterior  spine  of 
the  ilium,  q,  and  reach  the  aorta  from  the  side  by  raising  the  peri- 
toneum."^ 

2.  The  common  iliac  artery  (Fig.  208)  varies  from  three  quarters 
of  an  inch  to  three  inches  in  length,  averaging  about  two;^  it  passes 
from  the  bifurcation  of  the  abdominal  aorta,  on  the  left  side  of  the 

1  Sir  A.  Cooper.  2  Murray.  3  L.  Holden. 

17 


258  OPERATIVE  SURGERY. 

body  of  the  fourth  hunbar  vertebra,  a  point  corresponding  with  the 
left  side  of  the  umbilicus,  on  a  level  with  a  line  drawn  from  one  crista 
ilii  to  the  other,  downwards  and  outwards  along  the  mai'gin  of  the 
pelvis  to  the  sacro-iliac  synchondrosis;  the  artery  upon  the  right  side 
is  on  an  average  the  same  length  as  ^  that  upon  the  left,  and  has  in 
front,  the  peritoneum,  and  at  its  point  of  division,  the  ureter. 

Behind,  the  accompanying  vein,  J,  is  partly  external  above,  but  below  it  lies 
behind  and  slightly  internal;  on  the  outer  side,  the  common  iliac  vein  above, 
and  the  psoas  muscle,  >i,  below.  The  left  common  iliac  has  the  rectum  and 
superior  ha^morrhoidal  artery  in  front,  the  left  common  iliac  vein  internal  and 
partly  beneath,  and  the  psoas  magnus  external. 

The  patient  being  placed  on  the  back  (Fig.  208),  inclining  to  the 
opposite  side  :  make  an  incision,  R,  commencing  just  anterior  to  the  ex- 
ti'emity  of  the  eleventh  rib,  downwards,  one  and  a  half  inches  within 
the  anterior  superior  spine,  and  terminating  just  above  the  internal  ring 
by  a  sharp  curve  upwards  and  inwards  of  an  inch;  the  entire  length 
is  about  seven  inches  ;  divide  the  integuments  and  superficial  fascia; 
then  the  three  abdominal  muscles;  cautiously  raise  the  fascia  trans- 
versalis  from  the  peritoneum,  first  at  the  upper  part  of  the  wound 
where  the  union  is  slightest ;  now  gently  elevate  the  peritoneum  and 
press  it  inwards  from  the  iliac  fossa  towards  the  pelvis ;  the  pulsa- 
tions of  the  external  iliac,  f,  are  first  recognized,  and  the  finger  car- 
ried upwards  along  this  vessel  reaches  the  common  trunk  ;  the  ureter, 
H,  in  front,  is  carefully  pushed  aside,  and  the  needle  passed  from 
within  outwards. 

There  is  great  danger  of  lacerating  the  peritoneum,  both  in  the  act  of  separ- 
ating it  from  the  transversalis  fascia,  and  in  raising  it  from  the  iliac  fossa;  to 
avoid  the  tirst  accident  the  transversalis  fascia  should  be  lirst  raised  high  up  in 
the  wound,  where  the  attachments  are  the  slightest;  to  avoid  the  second,  the 
peritoneum,  with  the  inclosed  bowels,  o,  should  be  raised  on  the  palms  of  an 
assistant  standing  upon  the  opposite  side  of  the  patient,  while  the  surgeon  gently 
separates  with  his  lingers  its  attachments.  Other  methods  are  indicated  by 
the  incisions  B,  A,  C,  1. 

3.  The  internal  iliac  artery  (Fig.  208),  e,  is  an  inch  and  a  half 
in  length,  extending  from  the  bifurcation  of  the  common  iliac  down- 
wards and  forwards  to  the  upper  margin  of  the  gi'eat  sacro-sciatic 
foramen ;  it  is  in  relation  anteriorly  with  the  ureter,  H,  which  separ- 
ates it  from  tlie  peritoneum ;  posteriorly,  wiih  the  internal  iliac  vein; 
it  rests  on  the  sacral  plexus  of  nerves  and  the  pyriformis  muscle;  on 
the  left  the  rectum  lies  p:\rtially  over  it.  The  artery  may  be  readily 
exposed  and  ligated  by  the  method  described  in  the  operation  on  the 
primitive  iliac  ;  ^  or,  make  an  incision  five  inches  long,  half  an  inch 
outside  of  and  parallel  to  the  epigastric  artery  ;3  or,  make  an  incis- 
ion in  a  semicircular  form,  commencing  two  inches  to  the  left  of  the 
1  L.  Holden.  2  Stevens.  3  White. 


OPERATIONS  ON  THE   CIRCULATORY  SYSTEM.     2.39 


Fig.  209. 


unibilii'us,  and  eiuling  near  the  external  ring,  seven  inches  in  length, 
with  the  convexity  towards  the  ilium. 

4.  The  gluteal  artery  emerges  from  the  pelvis,  at  the  upper  part 
of  the  great  isi  lii:itic   notch,  above  the  upper 
border  of  the  pyriformis  muscles. 

It  is  covered  by  tlie  gluteus  inaximus  muscles, 
and  is  accompanied  by  two  veins;  a  line  drawn  from 
the  posterior  superior  ?p\v.e  of  the  ilium  to  the  top 
of  the  great  trocliantcr  marks  the  course  of  the  ar- 
tery. 

(Fig.  209.)  Place  the  patient  upon  his 
belly,  the  thigh  extended  ;  make  an  incision 
on  the  line  above  indicated,  four  or  five  inches 
long;  the  cut  is  parallel  with  the  fibres  of  the 
gluteus  niaximus,  which  should  be  separated, 
and  the  finger  introduced  to  detect  the  pulsa- 
tit)ns  of  the  artery;  separate  the  pyriformis 
and  gluteus  niedius  muscles,  the  borders  of 
which  cover  the  vessel,  and  isolate  the  artery 
from  its  veins  and  pass  the  needle. 

5.  The  sciatic  artery  escapes  from  the  pelvis  between  the  pyri- 
formis and  coccygeus  muscles,  and  descends  in  the  interval  between 
the  trochanter  major  and  tuberosity  of  the  ischium. 

It  is  covered  bj'  the  gluteus  maximus,  and  is  accompanied  by  the  sciatic 
nerve,  and  the  vein  which  lies  to  its  posterior  and  inner  side;  the  centre  of  a 
line  drawn  from  the  posterior  superior  spinous  process  of  the  ilium  to  the  tuber- 
osity of  the  ischium,  marks  the  point  of  exit  of  the  artery  from  the  pelvic  cavit}'. 

(Fig.  210.)  Place  the  patient  upon  the  belly;  make  a  vertical  in- 
cision, two  inches  in  length,  the  centre  of  which  falls  upon  the  point 
of  emergence  of  the  artery,  as  given 
above;  divide  the  skin,  cellidar  tissue, 
and  the  fibres  of  the  gluteus  maximus; 
the  artery  is  found  to  the  inside  of  the 
nerve,  and  must  be  carefully  isolated 
from  the  vein. 

6.  The  internal  pudic  artery,  the 
smaller  of  the  two  terminal  branches 
of  the  internal  iliac,  passes  out  of  the 
pelvis  through  the  great  saero  sciatic 
foramen,  internal  to  the  sciatic  artery;  ^  Fig.  210 
it  again  enters  the  pelvis  through  the  lesser  sacro-sciatic  foramen, 
runs  along  the  ramus  of  the  ischium  and  pubis,  and  divides  into  the 
arteries  of  the  jicnis. 

((/.)  At  the  greater  sacro-sciatic  foramen  make  the  same  incision 


260 


OPERATIVE  SURGERY. 


as  in  the  ligature  of  the  sciatic  artery;  the  pudic  is  found  a  little  in- 
ternal, accompanied  by  its  veins  and  the  pudic  nerve. 

(h.)  In  the  perineum  (Fig.  211)  the 
artery  may  be  ligated  as  it  descends 
the  ramus  of  the  ischium;  draw  a  line 
from  the  middle  of  the  pubes  to  the 
internal  border  of  the  tuber  ischii. 
The  patient  being  placed  in  the  posi- 
tion for  lithotomy,  make  an  incision 
two  inches  in  length  along  the  ramus 
of  the  pubis,  near  the  arch;  by  care- 
ful dissection  the  vessel  is  found  along 
the  inner  border  of  the  ramus,  where 
it  may  be  isolated  and  the  ligature 
applied;  care  shoidd  be  taken  not  to 
incise  the  corpus  cavernosum. 

7.    The    dorsalis    penis    artery 
reaches  the  dorsum   of  the  penis  by 
Fig.  211.  passing  between  the  crura,  and  runs 

forward,  through  the  suspensory  ligament,  in  the  groove  of  the  cor- 
pus cavernosum,  to  the  glans,  distributing  branches  in  its  course  to 
the  body  of  the  organ,  skin,  and  prepuce.  It  is  enveloped  in  the 
subcutaneous  layer,  and  is  accompanied  by  the  dorsalis  penis  nerve 
and  vein  ;  the  latter  structures  should  be  remembered  in  ligating  the 
artery.  Make  an  incision  three  fourths  of  an  inch  in  length,  com- 
mencing two  inches  in  front  of  the  pubes  directly  in  the  median  line; 
carry  the  incision  through  the  skin  and  superficial  lamina  of  the  sub- 
cutaneous layer,  when  the  artery  is  fully  exposed;  pass  a  small  artery 
needle,  carefully  avoiding  the  nerve.^ 

3.  The  external  iliac  artery,  about  four  inches  in  length,  passes 
obliquely  downwards  and  outwards,  from  the  sacro-iliac  symphysis 
to  Poupart's  ligament,  in  a  line  drawn  from  the  left  side  of  the  um- 
bilicus to  a  point  midway  between  the  anterior  superior  spine  of  the 
ilium  and  the  symphysis  pubis;  it  may  be  ligated  in  any  -pnvl  of  its 
course,  except  near  its  upper  and  lower  extremities. 

In  its  upper  portion  it  has  in  front  the  peritoneum  and  intestines,  and  near 
Poupart's  ligament  the  spermatic  vessels,  genito-crura!  nerve,  circumflex  iliac 
vein,  lymphatic  vessels  and  glands;  externally,  the  psoas  magnus,  m,  from 
which  it  is  separated  by  the  iliac  fascia;  internally,  the  external  iliac  vein; 
below,  and  curving  along  its  side,  the  vas  deferens;  behind,  it  rests  above  upon 
the  external  iliac  vein,  which  gradually  passes  to  its  internal  side. 

Place  the  patient  in  a  recumbent  position,  the  abdominal  muscles 
relaxed;  make  an  incision  three  or  four  inches  in  length  (Fig.  212), 

1  J.  C.  Hutchison. 


OPERATIONS   ON  THE   CIRCULATORY  SYSTEM.     2G1 

comniencinc!:  ahoiil  an  inch  and  a  half  within  the  antL-rior  superior 
spine  of  the  ilium  ami  on  a  level  with  this  process,  ami  extendin!;^  in 
a  curved  directiDU  down-  j 

wards  ami  inwards,  near-  ^  I 

ly  parallel  with  Poupart's  " J^^^^ \ 

ligament,   and   tenninat-  /T^^jj^v  \ 

inf]f  an  inch   and    a  half   l> ^./CT^^M^  \ 

above  it,  just  outside  of  J^^^^       ^  \ 

the    external    abdominal  [h^^J^^ y/  I 

ring;  on  the  left  side  it  ^■^)~^'~y'^  \ 

will  be  found  convenient  1 1      I    (  / 

to  commence  the  incision  1  I      I    I  ' 

internally,  at  the  exter-  Fi<^-  212. 

nal  ring  and  carry  it  upwards  and  outwards  to  the  point  indicated 
within  the  anterior  sujjerior  spine;  incise  the  integuments  and  fascia, 
and  tie  the  superficial  epigastric  artery,  if  divided;  the  aponeurosis, 
c,  of  the  external  oblique  muscle  is  now  exposed  and  divided  on 
a  director;  in  the  same  manner  divide  the  fibres  of  the  internal 
oblique  and  transvcrsalis  muscles,  a,  until  the  transversalis  fascia, 
recognized  by  its  white,  opaque  appearance,  is  exposed  ;  cautiously 
open  this  membrane  and  incise  on  the  director;  the  peritoneum,  (/, 
is  now  exposed  and  carefully  detached  from  the  iliac  fossa,  and 
pushed  towards  the  pelvis  ;  the  artery,  6,  is  readily  felt  pulsating 
at  the  bottom  of  the  wound,  along  the  inner  border  of  the  psoas 
muscle,  the  vein  being  on  the  inner  aspect,  the  genito  crural  nerve 
external;  open  the  sheath  and  insinuate  the  needle  beneath  it,  from 
within  outwards,  to  avoid  the  vein.  Or,  the  finger  may  be  passed 
into  the  internal  ring  along  the  spermatic  cord  and  the  iliac  fascia 
raised  in  this  manner. 

Other  incisions  i  are  made  in  the  course  of  the  artery  (Fig.  208,  a),  three  inches 
in  leufjfth;  a  curved  incision  (Fig.  208,  c),2  commencing  a  little  above  the  spine 
of  the  ilium,  and  terminating  a  little  above  the  internal  edge  of  the  inguinal 
ring;  an  incision  (Fig.  208,  b),3  in  the  centre  of  the  space  between  the  anterior 
superior  spine,  and  tlie  sjmphysis  pubis. 

9.  The  epigastric  artery  (Fig.  208,  o).  arises  from  the  anterior 
face  of  the  exteni:il  iliac  above  Poupart's  ligament. 

It  at  first  descends  and  (hen  passes  obliquely  upwards  and  inwards  between 
the  peritoneum  an<l  the  transversalis  fascia,  in  a  line  drawn  from  tlie  miihile  of 
Poupart's  ligament  to  the  unil)ilicus;  it  lies  behind  the  inguinal  canal,  and  to 
the  inner  side  of  the  internal  abdominal  ring;  it  has  two  veins  nearly  to  its 
origin. 

The  incisions  in  the  last  operation,  but  not  so  lon'jr,  are   equally 
adapted  for  li<raiing  this   artery;  the   spermatic  cord  is  first  sought 
1  Abernethy.  *  Cooper.  8  Bogros. 


262 


OPERATIVE  SURGERY. 


for,  and  being  raised,  the  innei'  border  of  the  internal  ring  is  ex- 
posed; the  ring  is  dilated  with  the  end  of  the  finger,  and  behind  the 
layer  of  transversalis  fascia  constituting  its  border  the  artery  is 
felt. 

10.  The  femoral  artery  extends  from  Poupart's  ligament  to  the 
tendinous  opening  in  the  adductor  magnus  muscle,  at  the  junction  of 
the  middle  and  lower  third  of  the  thigh,  in  a  line  drawn  midway 
between  the  anterior  superior  spine  of  the  ilium,  and  the  symphysis 
15ubis,  and  the  inner  side  of  the  internal  condyle. 

(fl.)  Beneath  Poupart's  ligament  the  artery  is  superficial,  being 
covered  by  the  skin,  superficial  and  deep  fascia3,  and  lymphatic 
glands ;  the  vein  lies  on  its  inner  side,  and  the  anterior  crural  nerve 
half  an  inch  to  its  outer  side;  the  vessels  lie  in  a  canal  formed  by  the 
parting  of  the  two  layers  of  the  fascia  lata,  and  are  separated  by  this 

septum.  The  pulsa- 
tions of  the  artery  be- 
ing recognized,  mid- 
way between  the  an- 
terior superior  spine 
of  the  ilium  and  the 
pubes,  make  an  in- 
cision two  inches  in 
length,  over  the  artery, 
commencing  at  the 
crural  arch ;  divide  the 
skin  and  cellular  tis- 
FiG.  -13.  gyg.  i-aise  the  fascia,  a, 

on  a  director,  and  expose  the  sheath;  open  it  and  draw  the  vein,  c, 
inwards,  and  jjass  the  needle  around  the  artery,  5,  from  within  out- 
wards, ligating  it  above  the  profunda  femoris.  The  incision  may  be 
parallel  1  with  Poupart's  ligament. 

In  persons  of  ordinary  flesh,  the  fold  of  the  groin  corresponds  exactly  with 
Poupart's  ligament,  but  in  those  who  are  very  fleshy  the  fold  is  somewhat  be- 
low Poupart's  ligament:  and  should  this  be  taken  as  the  guide  to  the  commence- 
ment of  the  incision  there  would  be  danger  of  applying  the  ligature  just  below 
the  origin  of  the  profunda;  it  is  advisable  to  bring  the  ligament  into  view  before 
the  ligature  is  applied,  and  pass  the  needle  a  finger's  breadth  below. 

(i.)  At  its  upper  portion  the  artery  lies  in  a  triangle,  Scarpa's 
space,  formed  by  Poupart's  ligament  above  as  its  base,  the  sartorins 
externally,  and  the  adductor  brevis  internally;  it  is  very  superficial, 
being  covered  by  integument,  the  superficial  and  deep  fasciae,  and 
lymphatic  <rlands ;  the  vein  is  on  the  inner  and  slightly  posterior 
part  (Fig.  214).     Ligate  near  the  apex  of  the  triangle  ;  flex  the  thigh 

1  Porter. 


OPERATIONS   ON  THE  CIRCULATORY  SYSTEM.    263 


slightly  on   tlic  body,   abduct   and   ])Iaco  it   on    its  external  aspect; 

inaku  an  incision  coinnienciipj;  al)out  four  inches  below  Poupart's  lif^- 

ament,     alonjr     the     inner 

margin     of     the     sartorii:s 

muscle,    three     inches     in 

length;  tlie  saphenous  vein, 

first    made     prominent    by 

pressure   above,  is   left   to 

the  inner  sid*-;  divide   tlu; 

fascia  lata,  a,   expose    aiu 

draw  outward  the  sartoiius, 

ft,   and   the   sheath   of    the 

vessels   becomes  apparent; 

the  position  of    the  artery 

is  recognized  by  its  pulsa-  Fig.  214. 

tions  ;    o\)CX\   the   sheath   to   a  sullicient  extent  to  pass  the  needle, 

which  is  cautiously  done  from  within  outwards  to  avoid  the  vein,  c: 

the  point  of  the  needle  should  be  kept  close  to  the  artery,  d,  as  the 

vein  lies  closely  on  its  inner  and  posterior  aspect. 

If  the  saphenous  vein  is  wounded,  compression  is  sufficient  for  its  treatment ; 
if  the  incision  fails  upon  tlie  sartorius,  this  must  be  drawn  aside. 

(c.)  At  its  middle  portion  the  artery  is  covered  bv  the  skin,  super- 
ficial and  deep  fascia',  and  sartorius,  and  is  contained  in  a  fibrous 
canal ;  the  femoral  vein  lies  on  the  outer  and  posterior  part  of  the 
artery,  and  the  long  saphenous  nerve  more  e.xternally.  Place  the 
limb  in  the  position  above  described,  and  make  an  incision  three  or 
four  inches  in  length  at  the  middle  of  the  thigh,  on  the  line  given, 
or  on  the  inner  border  of  the  sartorius  muscle,  its  upper  extremity 
being  si.x  lines,  and  the  lower  two  lines  from  the  internal  border  of 
that  muscle,  care  being  taken  to  avoid  the  internal  saphenous  vein, 
the  course  of  which  is  made  ajjparent  by  compression  above;  expose 
the  sartorius  by  dividing  the  fascia  laia;  draw  it  outwards;  expose 
and  divide  the  fibrous  connection  between  the  vastus  and  adductor 
muscles ;  the  sheath  of  the  vessel  now  appears,  which  is  readily 
opened,  and  the  needle  passed  from  within  outwards,  avoiding  the 
vein  and  long  saphenous  nerve. 

Ql.)  At  the  inferior  part  of  its  course  the  artery  enters  a  fibro  is 
sheath,  formed  by  the  fibrous  bands  which  extend  from  the  vastus 
internus  to  the  adductor  magnus  anil  lonirus,  having  over  it  the  sar- 
torius nmscle,  fascia?,  and  integuments  ''Fiir-  "215).  Flex  the  thigh 
on  the  pelvis,  and  the  leg  on  the  thigh,  the  limb  resting  on  its  exter- 
nal surface  ;  make  an  incision  three  inches  long  on  the  outer  margin 
of  the  sartorius  muscle,  if  recognized,  or  on  the  line  above  given;  the 


264 


OPERATIVE  SURGERY. 


skin  being  divided,  the  sartorius,  c,  recognized,  and  the  fascia,  a, 
divided  on  a  director,  two  hnes  within  its  external  border  ;    draw 
0  a  the    muscle    backwards    and    divide 

the  jjosterior  jjart  of  its  sheath ;  the 
space  between  the  vastus  internus  and 
adductor  niagnus  is  now  recognized, 
which  contains  the  canal  of  the  arte- 
ry ;  open  this  canal,  6,  on  a  director, 
and  the  artery,  d,  is  exposed,  with 
the  vein  on  its  inside,  and  the  saphe- 
nous nerve  on  the  outside ;  the  ves- 
sels are  united  by  very  dense  cellular 
tissue,  and  great  care  is  necessary  to 
isolate  the  artery. 

11.  The  popliteal  artery  extends 
from    the   oitcning   in    the    adductor 
magnus    to  the  lower  border  of  the 
popliteiis    muscle,  in    an  oblique  di- 
rection downwards  and  outwards. 

In  the  popliteal  space  the  external  saphenous  vein  runs  perpendicularly  in 
the  median  line,  and  in  the  middle  of  the  popliteal  space  perforates  the  deep 
fascia;  then  ascends,  winds  around  the  popliteal  nerve,  and  empties  into  the 
popliteal  vein.  It  is  accompanied  by  the  external  saphenous  nerve,  from  which 
it  is  separated  by  a  process  of  the  deep  fascia;  the  popliteal  nerve  passes  down 
the  middle  of  the  popliteal  space,  beneath  the  deep  fascia,  superficial  to,  and  on 
the  outside  of  the  popliteal  vessels,  from  which  it  is  separated  b}'  adipose  tissue; 
it  gives  off  the  external  saphenous  and  the  peroneal  nerves;  the  popliteal  ar- 
tery is  covered  in  its  whole  course,  and  crossed  at  the  middle  of  the  popliteal 
space,  by  the  popliteal  vein,  the  direction  of  which  is  vertical;  the  artery  always 
beneath  the  vein,  is  somewhat  internal  to  it 
above,  and  external  to  it  below;  the  ves- 
sels are  covered  superiorly  bv  the  belly  of 
the  semi-niembranosus;  below  they  pass  be- 
tween the  two  heads  of  the  gastrocnemius. 
They  are  connected  together,  throughout  j. 
their  course,  by  dense  cellular  tissue,  which  c^ 
renders  their  separation  difficult.  'i- 

(a.)  In  its  upper  part;  make  an 
incision  three  inches  in  length,  com- 
mencing at  the  inferior  third  of  the 
thigh,  and  passing  along  the  exter- 
nal margin  of  the  senii-membranosns 
muscle;  divide  the  .-kin  and  fa-cia;  separate  the  cellular  tissue  with 
the  director  and  finger:  now  flex  the  leg,  and  the  nerve  first  appears, 
then  the  vein  to  its  inside,  and  lastly  the  artery ;  pass  the  needle 
from  within  outwards. 


Fig.  216. 


OPERATIOXS  OX  THE   CIRCULATORY  SYSTEM.    2G.5 


Fig.  217. 


(J).)  In  its  lower  part;  (Fi:r-  21C)  the  patient  is  laid  on  his  face, 
the  k'<;  extendi'il,  ami  an  incision  made  through  the  inte<^ument, 
three  inches  lon<^,  s-liLdiily  on  the  outside  of  the  median  line;  the 
external  saphenous  vein,/",  which  lies  under  the  skin,  is  carefully 
avoided;  the  fascia,  n,  is  divided,  and  the  cellular  substance  in  the 
space  between  the  two  heads  of  the  gastrocnemius  is  separated 
with  the  finger,  exposing  the  popliteal  nerve,  c,  the  vein,  b,  and 
most  external,  the  artery,  d :  the  nerve  and  vein  are  drawn  inwards, 
and  the  needle  is  passed  from  within  outwards. 

(c.)  Below  the  internal  condyle  (Fig.  217);  place  the  patient  on 
his  back,  the  limb   flexed  and  lying   on  the  *    c  d   e  f 

outer  side;  standing  on  the  outside  feel  for  - 
the  internal  side  of  the  muscular  mass  bound- 
ing the  popliteal  space  internally  and  below; 
make  an  incision,  h,  two  and  a  half  inches 
in  length,  from  above  downwards,  from  with- 
out inwards,  and  from  i)ehind  forwards,  along 
the  edge  of  the  internal  head  of  the  gastro- 
cnemius, within  half  an  inch  of  the  internal 
border  of  the  tibia;  care  is  taken  to  avoid  the 
internal  saphenous  vein,/;  divide  the  aponeu- 
rosis a  little  farther  back  than  the  skin ;  intro- 
duce the  finger  to  break  down  the  intermuscular  septum,  the  leg 
being  flexed  on  the  thigh  to  relax  the  muscles;  at  the  bottom  of  the 
wound  is  seen  the  nerve,  e,  to  the  inside,  the  artery,  d,  and  the  ac- 
companyinir  Ni-in.  r.  drawn  rmtwards. 

1 2.  The  posterior  tibial  artery,  a  branch  of  the  popliteal  artery, 
extends  from  the  lower  border  of  the  popliteus  muscle,  in  an  oblique 
direction,  from  without  inwards  to  the  annular  ligament;  its  course 
is  in  a  line  commencing  in  the  centre  of  the  popliteal  space  and  ter- 
minating behind  the  internal  malleolus. 

(«.)  At  its  upper  third  the  artery  lies  very  deep,  being  covered  by 
the  tibialis  posticus,  the  deep  aponeurosis,  the  soleus,  and  the  gas- 
trocnemius. At  a  distance  of  two  thirds  of  an  inch  from  the  inter- 
nal border  of  the  tibia  make  an  incision  at  least  four  inches  in  length, 
through  the  integuments  and  deep  fascia;  carry  the  inde.x  finger 
into  the  wound,  detach  and  jMish  outwards  the  internal  liead  of  the 
gastrocnemius,  and  divide  also  the  attachments  of  the  soleus,  thus 
exposed,  from  the  posterior  surface  of  the  tibia:  whilst  an  assistant 
keeps  this  muscle  held  backwards  and  outwards  with  a  blunt  hook, 
divide  the  deep  layer  of  aponeurosis  upon  a  director,  and  search  for 
the  vessel  immeiliately  beneath;  detach  the  artery,  and  pass  the  lig- 
ature beneath  it  with  the  artery  needle. 

(/>.)  In  its  middle  third  the  artery  lies  superficial,  running  parallel 
with  the  inner  border  of  the  tibia,  from  which  it  is  separated  by  the 


266 


OPERATIVE  SURGERY. 


Fig.  218. 


flexor  longiis  digitorum ;  it  is  covered  by  the  internal  border  of  the 
soleus,  it  has  vense  comites,  and  the  posterior  tibial  nerve  is  on  its 
inner  side  (Fig.  218).      The  limb  is  placed  as  in  the  last  position, 

and  an  incision  made  tliree  inches  in 
length,  three  fourtlis  of  an  inch  pos- 
terior to  the  internal  border  of  the 
tibia;  the  integument  and  deep  fascia 
being  divided,  the  fore  border  of  the 
gastrocnemius,  d,  is  seen  and  drawn 
backwards,  exposing  the  soleus;  the 
fibres  of  this  muscle  should  be  di- 
vided on  a  director;  the  artery  is 
now  felt  pulsating  about  an  inch 
from  the  margin  of  the  tibia;  the 
peai'l-colored  deep  aponeurosis  which  overlies  is  divided,  and  then 
the  muscles  relaxed  by  the  position  of  the  limb;  the  artery,  c,  is 
isolated  from  its  veins,  h,  the  nerve  being  pressed  to  the  outside;  the 
needle  is  jjassed  from  without  inwards. 

c.  In  its  lower  third,  the  artery  passes  down  behind  the  internal 
malleolus,  running  at  first  parallel  with  the  tendo-Achillis,  and  then 
midway  between  the  internal  malleolus  and  the  tuberosity  of  the  os 
calcis  ;  it  is  very  superficial,  and  is  in  relation  anteriorly  with  the 
tendons  of  the  tibialis  posticus  and  flexor  longus  digitorum,  and  pos- 
teriorly with  the  posterior  tibial  nerve;  it  has  vente  comites.  (Fig. 
219.)     The  leg  being  placed  on  its  external  aspect,  the  foot  flexed, 

make  an  incision  two  inches 
in  length,  a  finger's  breadth 
posterior  to  the  inner  edge 
of  the  tibia,  and  parallel 
with  it  ;  the  integuments 
are  divided,  the  deep  fas- 
cia, a,  raised  on  a  director, 
and  a  small  mass  of  fat 
opened,  which  will  expose 
the  artery,  d,  and  the  venae 
comites,  c,  and  the  poste- 
rior tibial  nerve,  6 ;  the 
sheaths  of  tendons  should  be  carefully  avoided;  it  should  be  noticed 
that  the  artery  sometimes  lies  anterior  to  the  incision  here  given. 
The  artery  may  be  ligated  a  little  lower  by  making  a  cin-ved  incision 
one  third  of  an  inch  behind  the  external  malleolus.  At  this  part  of 
the  leg  the  anastomosis  of  large  branches  of  the  internal  saphenous 
vein  are  numerous,  and  generally  run  transversely;  these  may  be 
brought  out  Ijy  com])ressing  the  trunk  of  the  vein  above,  and  thus 
be  avoided,  at  least  in  part. 


Fig.  219. 


OPERATIONS  ON  THE   CIRCULATORY  SYSTEM.    207 


13.  The  anterior  tibial  artery  emerges  ui)on  the  anterior  part 
of  the  leg,  at  its  upper  part,  through  the  interosseous  uiembiMne,  and 
passes  down  to  the  ankle,  in  a  line  drawn  from  the  inner  side  of  the 
fibula  to  a  point  midway  between  the  two  malleoU;  it  may  be  ligated 
at  any  point  in  its  course. 

(a.)  In  its  upper  third  the  artery  Hes  deeply  between  the  tibialis 
antieus  and  extensor  longus  digitorum  ;  those  museles  having  their 
origin  in  part  from  the  deep  fascia,  the  intermuscular  septum  is  not 
easily  recognized,  nor  are  the  muscles  readily  se[)aratcd. 

The  limb  being  turned  inwards,  the  foot  extended,  take  as  a  guide 
the  line  already  given,  or  a  point  ten  lines  to  the  outer  side  of  the 
spine  of  the  tibia,  and  make  an  incision  about  four  inches  in  length 
through  the  integument;  divide  the  deep  fascia  with  a  crucial  in- 
cision to  allow  of  its  complete  separation  ;  the  intermuscular  septum 
is  now  sought  for,  and  may  be  recognized,  (1.)  As  the  first  intermus- 
cular space  from  the  tibia  ;  (2.)  on  pressure  from  within  outwards 
the  resistance  of  the  other  muscles;  (3.)  at  the  lower  part  of  the 
■wound  the  white  line  of  the  muscular  interspace  is  more  marked. 
Tlie  foot  being  Hexed,  separate  the  muscles  with  the  index  finger, 
and,  the  wound  being  held  apart,  expose  the  artery  with  its  two 
veins  and  nerve,  the  latter  being  outside;  pass  the  needle  from  with- 
out inwards. 

(h.)  In  its  middle  third  the  artery  is  covered  by  the  skin,  super- 
ficial and  deep  fascia ;  on  the  inner  side  it  has  the  tibialis  antieus 
muscle,  and  on  the  external  the  extensor  longus  digitorum  and  ex- 
tensor proprius  pollicis  (Fig.  220).  The  limb  being  placed  as  iu  the 
former  position,  make  an  incision  three 
inches  or  more  in  length,  in  the  course 
of  the  artery,  through  the  integument; 
the  septum  iu  the  deep  fascia  uniting 
the  two  muscles  is  recognized  by  a  ti 
■white  line ;  divide  it  longitudinally, 
and  also  by  a  crucial  incision;  flex 
the  foot  to  relax  the  muscles,  and  the 
wound  being  separated  by  drawing  the 
tibialis  antieus,  b,  internally,  and  the 
extensor  longus  digitorum  and  exten- 
sor proprius  pollicis,  externally,  the 
nerve  is  met  with   more   superficially  F^^-  220. 

than  the  artery,  d,  with  its  veins,  c ;  pass  the  needle  from  within 
outwards. 

(f. )  In  its  lower  third  tlu-  artery  is  covered  by  the  integuments 
and  fascia,  and  is  crossed  by  the  extensor  pro|)rius  jiollicis  ;  it  lies 
at  first  between  the  tibialis  antieus  muscle  and  the  extensor  proprius 


268 


OPERATIVE  SURGERY. 


pollicis,  the  latter  muscle  crossing  to  the  inner  side  ;  the  artery  lies 
between  tlie  tendon  of  this  muscle  and  that  of  ^the  extensor  longus 
dip-itorum ;  it  is  accompanied  by  venas  comites,  and  the  anterior 
tibial  nerve,  which  here  lies  to  the  outer  side. 

The  leg  being  placed  in  a  horizontal  position,  the  foot  extended, 
and  the  tibialis  anticus  muscle  recognized,  make  an  incision  along 
the  external  border  of  that  muscle,  on  the  line  already  indicated, 
three  inches  in  length,  but  not  extending  to  the  annular  ligament ; 
carefully  incise  the  deep  fascia  on  a  director,  and  find  the  space  be- 
tween the  tibialis  anticus  and  extensor  proprius  pollicis,  and  sepa- 
rate the  two  muscles  with  the  index  finger;  now  flex  the  foot,  and 
expose  the  artery,  resting  on  the  tibia  with  the  nerve  superficial  to 
it;  isolate  it  from  the  two  veins,  and  pass  the  needle  from  within 
outwards,  the  nerve  being  drawn  inwards.  If  the  incision  falls  be- 
tween the  extensor  ])roprius  pollicis  muscle  and  the  extensor  com- 
munis digitorum,  the  ligature  may  still  be  applied. 

14.  The  dorsalis  pedis  artery  terminates  the  anterior  tibial, 
and  runs  in  a  line  drawn  from  the  middle  of  the  intermalleolar 
space,  measured  from  the  extremities  of  the  malleoli  to  the  space 
between  the  first  metatarsal  bones. 

It  is  covered  by  the  integuments,  fascia,  and  innermost  tendon  of  the  exten- 
sor brevis  digitorum  ;  on  its  inner  side  is 
the  extensor  proprius  pollicis,  and  exter- 
nally, the  inner  tendon  of  the  extensor 
longus  digitorum ;  it  has  two  veins,  and 
on  its  external  aspect  is  the  anterior  tibial 
nerve. 

Make  an  incision  (Fig.  221)  two 
inches  in  length  on  the  line  indi- 
cated, l>eing  parallel  to  the  external 
border  of  the  tendon  of  the  extensor 
projirius  pollicis  muscle,  c ;  divide 
the  skin  and  deep  fascia,  on  a  direc- 
tor, and  draw  the  internal  division 
of  the  extensor  brevis  digitorum,  a, 
outwards,  exposing  the  artery,  d, 
and  its  accompanying  veins,  h;  the 
nerve  is  on  the  outside;  pass  the 
needle  from  within  outwards. 
1.5.  The  peroneal  artery  arises  from  the  posterior  tiliial,  and  runs 
along  the  inner  border  of  the  fibula  to  the  outer  side  of  the  os  calcis; 
its  course  is  marked  by  a  line  drawn  from  the  posterior  part  of  the 
head  of  the  fibula  to  the  external  border  of  the  tendo-Achillis,  at  the 
malleolus ;  it  may  be  ligated  just  below  the  middle  of  the  leg.     The 


Fig.  221. 


OPERATIONS  ON  THE   CIRCULATORY  SYSTEM.    2G9 


foot  bein;^;  extended,  make  an  incision  two  or  three  inches  long,  one 
or  two  lines  behind  the  external  e<lge  of  the  fibula  and  parallel  with 
it;  if  the  soleus  is  met  with,  it  must  be  sepai-ated  from  the  fibula 
and  drawn  inwards  ;  the  edge  of  the  bone  being  now  exposed,  sepa- 
rate the  attachments  of  the  Hexor  poUicis  proprius  to  lis  po^terio^ 
surface,  and  the  artery  is  found  at  its  internal  side  ;  the  muscle  has 
a  stron<4  aponeurosis  on  its  anterior  surface,  which  must  be  divided, 
as  the  artery  lies  under  it. 

III.    TIIK  VEINS. 

1.  Venesection,  or  blood-letting  from  a  vein,  is  performed  with 
the  thunilj  laiKOt ;  this  instrument  may  have  a  very  blunt  or  a  very 
acute  j)oint;  the  former  is  preferred  in  operations  on  superficial, 
the  latter  on  deep-seated  veins.  The  patient  may  be  seated  or  re- 
cumbent, but  in  general  the  position  should  be  cho?en  which  most 
enlarges  the  vessels  ;  stop  the  flow  of  blood  to  the  heart  by  a  ligature 
applied  around  the  part  on  the  proximal  side  of  the  point  selected 
for  the  operation,  sufficiently  firm  to  close  the  veins  and  still  leave 
the  arteries  unobstructed  ;  the  veins  now  become  prominent  unless 
the  person  is  very  fleshy,  when  the  position  of  the  vein  must  be 
determined  by  its  corded  feel ;  place  the  thumb  of  the  left  hand 
firmly  on  the  vein  (Fig.  '222),  a  little  to  the  distal  side,  to  prevent 
the  vessel  from  rolling  on  the  attempt  to 
puncture  it ;  hold  the  lancet  between 
the  thumo  and  index  finger  of  the  right 
hand,  the  blade  at  an  obtuse  angle  with 
the  hand  ;  plunge  it  into  the  vein  ob- 
liquely to  its  transverse  diameter,  and 
the  hand  being  fixed,  elevate  the  point 
of  the  lancet  so  as  to  cut  its  way  out. 

The  success  of  the  operation  is  deter- 
mined by  the  flow ;  if  this  should  be 
slight,  it  may  be  due  to  too  small  an  ori- 
fice, which  should  then  be  enlarged  ;  or 
to  a  mass  of  protruding  fat,  which  may 
be  pushed  aside.  If  an  increased  flow  is 
required,  the  patient  should  be  directed  to 
grasp  repeatedly  the  staff,  or  the  operator 
may  rub  the  limb  from  the  wrist  towards 
the  elbow.  When  the  proper  amount  of 
blood  is  drawn,  as  proved  by  the  fainting  of  the  patient,  the  band 
should  be  removed,  and  a  small  compress  being  placed  over  the 
wound,  apply  a  figure-of-eight  bandage  ;  to  prevent  air  entering  the 
circulation  in   bleeding  from  the   jugular,  pressure  on  the  wound 


Fig.  222. 


270  OPERATIVE  SURGERY. 

should  be  made  before  the  compress  is  removed.  Blood  may  be 
taken  from  any  of  the  superficial  veins,  but  those  of  the  neck,  the 
bend  of  the  arm,  and  at  the  ankle,  are  generally  selected.  In  the 
neck  the  external  jugular  is  preferred.  Place  a  compress  over  the 
vein  in  the  supra-clavicular  fossa,  and  firmly  retain  it  by  a  bandage 
passed  over  it  and  under  the  opposite  axilla;  place  the  index  finger 
of  the  left  hand  upon  the  vein  above,  and  make  the  incision  upwards 
and  outwards  across  the  platysma  myoides.  At  the  bend  of  the 
elbow  select  the  cephalic  vein  on  account  of  its  isolation ;  the  basilic 
is  the  largest,  but  the  brachial  artery  passing  directly  under  it  is  in 
danger  of  being  wounded;  first  determine  the  position  of  the  artery, 
then  pass  a  band  firmly  around  the  arm  above  the  elbow;  with  his 
hand  the  patient  must  grasp  a  staff;  standing  in  front  of  the  patient, 
grasp  the  arm  with  the  left  hand,  placing  the  thumb  on  the  dis- 
tended vein,  and  the  fingers  on  the  back  of  the  elbow,  and  holding 
the  lancet  in  the  right,  open  the  vessel.  At  the  ankle  select  the  in- 
ternal saphena;  first  place  the  foot  in  a  vessel  of  warm  water  to  dis- 
tend the  veins,  then  pass  a  band  around  the  leg,  just  above  the  mal- 
leoli; place  the  thumb  on  the  vein,  and  open  it  just  above  the  inner 
ankle,  with  an  oblique  incision. 

2.  Transfusion  is  the  injection  of  the  blood  of  one  person  into 
the  blood-vessels  of  another  to  relieve  extreme  exhaustion.  It  is 
more  useful  after  severe  hasmorrhages  when  the  vascular  tension  is 
slight,  than  in  chronic  diseases  in  which  the  vessels  are  already  filled 
to  about  their  natural  capacity  ;  in  the  latter  cases,  especially  if 
associated  with  fatty  degeneration  of  the  heart,  but  a  small  amount 
of  blood  should  be  introduced  at  one  sitting — six  ounces  —  lest  too 
much  strain  be  placed  upon  the  heart. ^  The  operation  is  performed 
ujion  the  veins,  and  the  blood  may  be  transferred  directly  from  one 
person  to  another.  Or  it  may  first  be  drawn  into  a  vessel  and  then 
be  injected.     Immerse  the  apparatus  (Fig.  22.3)2  i,^  ^  basin  of  tepid 

water  and  expel  the  air  by 
compressing  the  bulb  ;  select  a 
prominent  vein  at  the  bend  of 
the  elbow  ;  place  a  bandage  on 
the  arm  ;  raise  a  fold  of  skin 
over  the  vein;  transfix  and  di- 
vide ;  seize  the  vein  with  fine 
forceps,  and  make  a  V  incision  with  scissors  ;  take  the  tube,  a,  from 
the  water  with  the  thumb  over  its  orifice  to  keep  it  full,  and  insert 
it  into  the  vein  ;  the  arm  of  the  blood  donor  is  now  brought  into 
close  proximity,  and  the  vein  opened,  and  the  tube,  b,  inserted  as 
described;  the  India-rubber  part  of  the  apparatus,  filled  with  water 
1  J.  R.  Chadwick.  2  j.  h.  Aveling. 


OPERATIONS  ON  THE   CIRCULATORY  SYSTEM.    271 


Fig.  224. 


ami  kept  so  by  turning  tlie  cocks  at  each  end,  is  now  fitted  into  tlie 
two  tubes ;  the  cocks  are  now  oj)ened  and  the  injection  commenced  by 
compressing  the  India-rubber  tube  on  the  efferent  side,  d,  and  s(jueez- 
ing  the  bulb,  c ;  this  forces  two  drachms  of  water  into  the  afferent 
vein  ;  ne.xt  shift  the  hand  from  d  to  d',  and  compress  the  tube  on  the 
afferent  side,  allowing  the  bulb  to  expand  slowly,  when  blood  will  be 
drawn  into  it  from  the  efferent  vein;  by  repeating  this  process,  any 
quantity  of  blood  can,  at  a  desired  rate,  be  transmitted,  the  amount 
being  measured  by  counting  the  number  of  times  the  bulb  is  emptied. 
The  blood  may  first  be  re- 
ceived into  a  vessel  (Fig. 
224)  and  then  be  pumped 
from  the  lijwer  part  of  the 
cup  through  a  canula  into 
the  veins  of  the  patient;  or 
the  blood  may  be  received 
into  a  vessel,  if  desired, 
and  defibrinated  by  whip- 
ping it  with  a  fork,  and 
then  injected  with  a  com- 
mon anatomical  syringe,  the  blood  and  instruments  being  maintained 
at  the  temperature  of  100°  F. 

Or,  isolate  a  subcutaneous  vein  at  the  bend  of  the  elbow,  or  the  large  saphe- 
nous in  front  of  the  inner  malleolus  by  a  free 
incision  through  the  skin  and  tissues,  and 
pass  under  it  a  catgut  ligature  at  each  tnd 
of  the  wound  ;  tie  the  distal  ligature,  raise 
tlie  vein  between  the  two  ligatures  by  a  small 
pair  of  toothed  forceps,  and  with  a  pair  of 
scissors  directed  towards  tlie  proximal  por- 
tion make  an  oblir|ue  incision  with  a  long 
flap;  raise  the  flap  and  introduce  the  nozzle 
of  the  canula  (Fig.  22"))  made  of  glass,  hard 
rubber,  or  silver,  and  retain  it  in  position  by 
tj-ing  the  second  ligature. i 

3.  Intra-venous  injection  of  milk^ 
is  now  recognized   as  a  perfectly  feas-  pj„   225. 

ible  and  legitimate  procedure,  not  only 

after  haMnorrha'Te.  but  in  disorders  which  greatly  depreciate  tlie  blood, 
as  cholera,  pernicious  ana?mia,  typhoid  fever: ^  it  is  infinitely  easier 
than  transfusion,  and  anyone  at  all  familiar  with  surgical  operations 
may  practice  it  without  fear  of  great  difiiculty  or  failure:  the  in- 
strument required  is  a  glass  funnel  with  a  rubber  tube  attached  to 
it,  ending  in  a  very  small  canula;  the  milk  should  be  removed  from 
1  F.  Esmarch.  2  £.  M.  Hodder.  8  t.  G.  Thomas. 


272  OPERATIVE  SURGERY. 

a  healthy  cow  within  a  few  minules  of  its  injection,  and  may  be  re- 
ceived into  a  warm  pitcher  covered  with  carbohzed  gauze,  through 
■which  it  is  strained;  open  the  median  basiUc  or  cephaUc  vein  by 
a  V  incision  (Fig.  225)  introduce  the  canula,  and  allow  the  milk 
to  flow  in;  not  more  than  eight  ounces  should  be  injected  at  once. 
It  is  commonly  followed  by  a  chill  as  in  transfut^ion,  and  rapid  and 
marked  rise  of  tempernture,  then  all  subsides  and  great  improvement 
shows  itself  in  the  patient's  condition. 

IV.    THE    CAPILLARIES. 

Local  blood-letting  is  the  withdrawal  of  blood  from  the  capillaries 
of  a  part  to  relieve  the  congestion  of  organs  or  tissues.  The  seat  of 
operation  must,  therefore,  be  selected  with  great  care  to  obtain  its 
full  benefit.  The  exact  area  of  arterial  and  venous  distribution 
must  be  made  out  in  each  case,  and  blood  sliould  be  taken  at  that 
point  where  the  vessels  are  most  nearly  and  readily  reached;  as  the 
mastoid  process,  for  the  sinuses,  in  congestion  of  the  eye,  ear,  or 
base  of  the  brain;  the  angle  of  the  jaw  for  the  veins  of  the  tonsils 
and  pharynx  in  tonsilitic  and  pharyngeal  inflammation;  the  thyroid 
body  for  the  plexus  of  veins  in  congestions  of  the  face,  neck,  and 
heart;  the  intercostal  spaces  for  the  arteries  and  veins  in  pleurisy; 
the  third,  fourth,  and  fifth,  left  intercostal  spaces  for  the  internal 
mammary  vein  in  pericarditis;  the  abdominal  wall  in  peritonitis;  the 
anus  for  the  portal  veins  in  inflammation  of  the  viscera  of  the  ab- 
domen;  the  spermatic  cord  for  orchitis;  the  regions  of  the  joints  for 
arthritis;  the  surface  of  limbs  fo»  periostitis. 

1.  Leeching  is  local  blood-letting  by  the  application  of  leeches; 
a  good  leech  is  estimated  to  draw  3ij,  and  j  ss.  more  will  flow  if 
fomentations  are  employed.  Select  active,  healthy,  Swedish  leeches, 
and  remove  them  from  the  water  an  hour  before  their  application; 
cleanse  the  part  to  be  leeched  of  all  irritating  matter,  and  hairs,  and 
smear  the  surface  with  milk  ;  place  the  leeches  in  a  leech-glass,  or 
in  a  tumbler  or  similar  vessel,  and  invert  it  upon  the  part;  if  it  is 
desirable  to  apply  a  leech  accurately  to  a  limited  space,  as  in  the 
angle  of  the  eye,  the  internal  part  of  the  nose,  mouth,  vagina,  a 
leech-glass,  or  tube  made  of  card-board,  or  other  similar  material 
should  be  used  to  hold  the  leech  and  fix  its  attachment;  avoid  the 
upper  eyelid  and  require  the  recumbent  position  for  some  time  to  pre- 
vent ecchymosis  of  parts  about  the  eye;  use  the  speculum  in  apply- 
ing leeches  to  the  os  uteri,  and  bring  the  neck  well  into  its  cavity; 
plug  the  OS  with  a  pledget  of  lint  to  prevent  the  escape  of  a  leech 
into  the  uterus;  if  the  leech  does  not  drop  after  being-  filled  apply 
salt  to  the  body.  To  promote  the  flow  from  leech-bites  apply  warm 
moist  dressings,  as  wet  flannel  cloths,  or  poultices;  to  arrest  bleeding, 


OPERATIOXS   ON  THE   CIRCCLATORY  SYSTE^f.     273 


^ 


Fig.  226. 


apply  a  dry  cloth,  s[)oiii4e,  or  pickud  lint,  with  pressure,  or  touch  the 
bite  with  nit.  ari;.  or  j)ersulph.  ferri;  in  e.xtrcine  cases  pass  a  threaded 
needle  through  the  cellular  tissue  under  tlie  bite  and  wind  the  thread 
firmly  around  under  the  needle. 

The  artificial  leech  is  a  tube  one  eighth  of  an  inch  in  diameter, 
having    a   cutting  eilge  ^  ^^^j 

at  one  extremity  (Fig. 
226) ;  it  is  wound  up 
by  the  button,  a;  press- 
ure at  d  releases  the  spriu',:.  .tnd  the  cutting  edge,  c,  cuts  circularly 
to  the  requisite  depth  as  fi.\ed  by  b;  to  this  cut  apply  a  light  glass 
tube  (Kig.  227)  from  which  the  air  is 
expelled  by  a  few  tlrops  of  ether  poured 
into  it,  and  then  immersed  as  far  as  the  L^ 
mouth  in  hot  water  until  the  ether  boils 
briskly.  Each  tube  will  draw  about  two 
ounces  of   blood;    for   uterine    practice  lie.  22i. 

they  are  made  long  enough  to  be  applied  through  a  speculum. 

2.  Scarification  is  a  form  of  local  blood-letting  by  incising  the 
capillaries  of  the  intlamed  part,  as  in  intlammation  of  the  skin,  the 
subcutaneous  connective  tissue,  the  tongue,  the  conjunctiva;.  Select 
a  sharp  lancet,  or  knife,  and  make  incisions  on  the  part  of  greater 
or  less  length  and  depth,  according  to  the  scat  and  extent  of  ihe 
congestion;  fomentations  will  continue  the  flow  of  blood;  if  the 
bleeding  is  too  free  or  long  continued,  use  lint  and  pressure,  if 
necessary,  externally,  and  persulph.  ferri,  if  the  incisions  are  in  cav- 
ities. 

3.  Cuppiug  is  a  method  of  abstracting  or  withdrawing  blood  from 
an  indaincd    part    by  creating  a  vacuum   in  a  vessel   applied   to  the 

neighboring  integument,  with  or  without  incisions; 

the  former  ^s»s^     <l2: 

is  wet,  the  ^;;^il ^,       , 


latter  dry, 

cupping.  Wet  cupping  re- 
quires the  scarificator,  the 
cup.  and  spirit  lamp.  The 
scarificator  (Fig.  228)  has 
Fig.  228.  a  number  of  lancets  whose 
protrusion  beyond  the  face  of  the  case  is 
adjustable;  these  are  set  in  a  retracted  po- 
sition, and  simultaneously  discharged  by  a 
pull  on  the  ca'ch.  The  cup  is  a  small  glass 
or  metallic  cup,  having  a  smooth  mouth.  Apply  the  .«cnrilicator  in 
wet  cupping;  moisten  the  internal  surface  of  the  cup  with  alcohol, 
18 


Fig.  220. 


274 


OPERATIVE  SURGERY. 


and  by  means  of  a  wi-p  of  paper,  or  rag,  wet  with  alrohol,  on  a  «lick, 
set  fire  to  the  alcohol  in  the  euj),  which  should  be  instantly  inverted 
over  the  scarifications  on  the  ])lace  selected ;  the  vacuum  created  by 
the  burning  alcohol  causes  the  integument  to  rise  in  the  cup  and 
thus  the  blood  is  forced  out  of  the  capillaries  in  wet,  and  stagnates 
in  dry,  cupping.  The  cup  may  have  a  suction  pump  attached  (Fig. 
229);  the  receiver  a  is  connected  by  a  fiexible  pipe  h  with  the  nozzle 
of  an  ordinai'y  syringe  c ;  the  sides  of  the  concentric  cliamber  afford 

an  extended  bearing  for 
the  cup,  and  prevent  its 
being  driven  into  the  in- 
tegument by  the  pressure 
of  the  atmosphere.  The 
cupping  apparatus  may 
have  a  lip  attached  to  the 
Fig.  230.  glass  cylinder  suitable  for 

application  to  the  skin,  or  to  the  nipple  when  used  as  a  breast  pump 
(Fig.  230) ;  a  central  rod  a  has  a  disk  with  lancets  which  act  as 
scarifiers,  and  the  air  is  exhausted  from  the  cylinder  by 
means  of  a  piston  in  the  tube  b  attached  ;  the  air  pump 
may  be  used  as  a  syringe  when  detached  fi-om  c,  the 
blood   receiver.      In    a   very  portable   cupping-instru- 
ment (Fig.    231)   the   glass  has   an   elastic    bulb  h  by 
which  the  partial  exhaustion  is  effected,  and  has  also 
an    adjustable   disk    provided   with    puncturing   points 
to  lance  or  irritate  the  skin.     The  scarifier,  cup,  and      F'g.  2-31. 
suction,  mav  also  be  combined  in  one  instrument  (Fig.  232),  where 

exhaustion  being  first  pro- 
duced in  gr,  the  ncedlebar, 
h,  is  thrust  down,  forcing 
the  needle,  l\  into  the  in- 
tegument, the  spring  re- 
turning the  needle-bar  and 
disk  to  position.  In  emergencies,  scarifications  may  be  made  with 
the  lancet  or  knife,  and  common  cups  or  small  table-glasses  may  be 
used. 


Fig.  2.32. 


V. 

THE    NERVOUS    SYSTEM. 

THE  BRAIN;    THE   SPINAL  CORD;    THE  NERVES. 


CHAPTER   XXIV. 

INJURIES   OF  THE   NERVOUS   SYSTEM,   AND  SPECIAL 
OPERATIONS. 

Inclosed  within  the  skull  and  the  vertebral  canal,  the  cerebro- 
spinal axis  is  protected  by  the  bony  walls  of  those  two  cavities;  it 
is  surrounded  by  (1)  a  dense  fibrous  membrane,  the  dura  mater, 
placed  most  superficially;  (2)  a  serous  membrane,  the  arachnoid; 
(3)  a  hiiihly  vascular  membrane,  the  pia  mater;  these  two  parts,  the 
encephalon  and  spinal  cord,  are  continuous  structures.^ 

I.  THE  BRAIN. 
1 .  Concussion,-  or  violent  commotion  of  the  brain,  may  cause 
slight  and  temporary  effects,  or  may  produce  irreparable  organic 
change  in  its  structure  without  palpable  laceration  or  contusion  of 
any  particular  part.  The  symptoms  are  usually  mixed  with  those 
due  to  other  complicating  injuries;  so  far  as  the  symptoms  of  con- 
cussion may  be  isolated,  the  milder  forms  present  the  general  indica- 
tions of  shock,  manifested  by  giddiness,  confusion  of  intellect,  totter- 
ing gait,  functional  disturbance  of  the  senses,  sympathetic  irritabil- 
ity of  stomach,  and  fall  of  temperature.  In  fatal  concussion,  death 
occurs  from  shock  rather  than  from  direct  injury  to  the  brain.  The 
treatment  must  always  be  directed  with  reference  to  the  possible 
complication  of  fracture ;  perfect  quiet  is  always  necessary;  if  the 
shock  is  severe,  stimulate  the  skin  by  friction.s,  warmth,  mustard 
j)aste;  apply  ammonia  to  the  nose,  and  if  necessary  give  small  doses 
of  brandy;  avoid  too  great  reaction;  when  it  occurs,  moderate  its 
effects  upon  the  brain  by  shaving  the  head  and  applying  ice;  if  no 
1  Quain's  Anatomy.  2  p.  Le  G.  Clarke. 


276  OPERATIVE  SURGERY. 

complications  appear,  continue  rest  and  freedom  from  all  mental  dis- 
turbance for  from  one  to  four  or  five  weeks,  according  to  the  severity 
of  the  shock. 

2.  Contusion,  or  bruising,  of  the  brain  ^  occurs  in  many  cases 
of  concussion;  the  blood  may  be  found  extravasated  in  circumscribed 
patches,  or  these  spots  may  be  disseminated  throughout  various  parts 
of  the  cerebral  mass ;  bruising  is  far  more  frequent  on  the  under 
than  the  upper  surfaces  of  the  cerebrum  and  cerebellum,  and  seldom 
occurs  in  the  pons  or  medulla  oblongata;  it  is  rarely  limited  to  the 
region  of  injury;  in  fissure  the  bruised  part  is  frequently  far  away, 
or  opposite  the  seat  of  the  blow.  The  lesion  is  marked  by  no  char- 
acteristic signs  ;  contusion  may  legitimiitely  be  inferred  whenever 
the  symptoms  are  severe  after  injury  of  the  head.  It  is  always  a 
grave  accident,  chiefiy  from  the  liability  to  inflammation  of  the  sur- 
rounding substance  immediately  or  remotely.  The  treatment  is  pre- 
vention of  inflammation,  and  in  detail  the  same  as  is  required  in 
concussion. 

3.  Compression  of  the  brain  is  that  condition  which  exists 
when  pressure  is  made  on  the  cerebral  mass  to  such  an  extent  as  to 
diminish  or  obliterate  its  functions.  The  symptoms  of  well-marked 
compression  are  those  of  apoplexy,  the  pulse  has  a  slow  and  full 
beat,  the  pupils  are  fixed  and  generally  dilated,  and  voluntary  move- 
ment and  sensation  are  partially  or  entirely  suspended ;  there  is 
stertor,  paralysis  of  the  sphincters;  the  temperature,  Avhich  is  no 
measure  of  the  amount  of  lesion  of  the  brain,  may  fall  to  94°  F.  or 
93°  F.,  and  recovery  follow. ^  The  cause  of  the  compression  may 
be  depressed  bone,  when  the  symptoms  will  immediately  follow  the 
injury;  or  extravasated  blood,  when  the  symptoms  will  gradually 
supervene  ;  or  a  collection  of  pus,  which  is  always  preceded  by  in- 
flammation; or,  finally,  compression  by  bone  and  extravasation  of 
blood  within  the  brain  from  laceration  may  coexist.^  The  precise  seat 
of  compression  may  be  determined  in  cases  of  compound  fracture 
with  depression,  with  the  jH'obe  or  finger,  and  also  the  exact  amount 
of  depressed  bone  may  be  defined.  If  there  is  no  external  injury,  the 
special  nerves  paralyzed  must  be  the  guide  to  the  point  of  pressure; 
l[)ut  this  symptom  has  only  a  general  significance  and  value  owing  to 
the  extent  of  internal  injury  which  usually  exists.  If  there  is  right 
hemiplegia,  compression  is  usually  on  the  left  hemisphere;  but  at  what 
precise  point  it  may  be  impossible  to  determine  by  any  peculiarity  in 
the  paralysis.*  The  treatment  aims  at  the  removal  of  the  cause  of 
com[)ression.  If  the  cause  is  unknown,  and  the  seat  of  pressure 
cannot  l)e  satisfactorily  made  out,  direct  perfect  quiet;  apply  cold 
to  the  head  to  prevent  inflammation,  and  give  saline  cathartics  to 
1  P.  Hewitt.        2  F.  Le  G.  Clarke.         3  x.  Hohnes.         4  e.  Biowii-S(?quard. 


INJURIES  OF  THE  NERVOUS  SYSTEM.  277 

promote  absorption;  sustain  the  strength,  and  depend  upon  time  for 
recoverv.  If  there  is  depressed  bone,  or  if  there  is  evidence  of  ex- 
travasation of  lilood  between  the  bone  and  dura  mater  at  the  seat  of 
injury,  proct'cd  at  om-e  to  trephine. 

4.  Wounds  of  the  brain  and  membranes'  may  be  punctured, 
cut,  or  lacerated;  these  lesioAs  are  not  necessarily  fatal,  thoutjh  as  a 
rule  they  are;  death  may  ensue  without  reaction,  or  aftir  intiamma- 
tion  is  developed.  The  symptoms,  when  unaccompanied  by  pres- 
sure, are  frecjuently  not  developed  until  inflammation  ensues,  and 
therefore  the  diagnosis  is  necessarily  obscure  ;  or  the  nature  of  the 
lesion  may  be  overlooked  until  there  are  indications  of  brain  dis- 
turbances, after  an  interval  of  three  or  four  da\s,  or  longer.  Ex- 
amination with  tl!e  finger  or  probe  determines  the  nature,  and  par- 
tially the  extent,  of  the  injury.  The  treatment  is  designed  to 
prevent  inflammation  and  its  consequences.  The  hair  should  be 
shaved,  fragments  of  bone  or  foreisrn  matters  lodged  in  the  wound 
removed,  and,  if  necessary,  the  wound  must  be  enlarged  by  the  tre- 
phine; having  thoroughly  cleansed  and  disinfected  the  wound,  bring 
the  integuments  together  and  retain  them  with  adhesive  or  elastic 
plaster  ;  apply  ice-bladders;  enjoin  perfect  quiet,  with  saline  cathar- 
tics, and  low  diet.  If  inflammation  follows,  the  brain  is  liable  to 
protrude  at  the  wound,  creating  a  hernia  cerebri,  and  abscess  may 
form. 

5.  Fissure  of  the  skull  ^  accompanying  scalp  wound,  but  unat- 
tended by  brain  disturbance  after  subsidence  of  the  shock,  is  not 
infrequent;  fissure  may  be  detected  through  the  wound,  though  there 
is  no  displacement ;  or  there  may  be  inequality  of  the  line  of  frac- 
ture, indicating  some  depression,  without  brain  injury.  These  cases 
reqiure  the  treatment  for  concussion,  with  long  continued  abstinence 
from  any  and  every  source  of  excitement. 

6.  Fractiires  and  fissures  '  wdiich  extend  to  the  base  of  the  skull 
are  diagnosed  with  dilliculty.  Ecchyniosis  in  the  mastoid  region,  or 
the  pharynx,  or  the  eye,  are  rare  and  uncertain  signs;  pharyngeal 
extravasation  is  most  important;  when  ecchymosis  appears  first, 
some  thirty-six  hours  after  the  injury  on  the  ocular  conjunctivae, 
and  spreads  to  the  lids,  it  is  pathognomonic  of  this  form  of  fracture; 
the  oozing  of  blood  and  serum  from  the  ear  is  diagnostic  of  fracture 
of  the  petrous  bone  only  when  limpid  fluid  is  supplied  in  abundance, 
and  contains  an  excess  of  chloride  of  sodium;  paralysis  of  the  facial 
and  auditory  nerves  is  only  a  suspicious  symptom,  and  must  be  taken 
in  connection  with  the  other  evidences,  for  it  may  result  from  in- 
flammation or  ])ressnre.  The  treatment  is  long-contiuued  rest,  low 
diet,  saline  cathartics. 

1  F.  Le  G.  Clarke. 


278  OPERATIVE  SURGERY. 

7.  Fracture  of  the  skull  i  is  of  comparatively  little  importance, 
except  so  far  as  it  is  accompanied  by,  or  entails  as  a  sequence,  mis- 
chief to  the  brain;  therefore,  as  a  general  principle,  the  presence  of 
fracture,  unattended  by  cerebral  symptoms,  rarely  demands  or  justi- 
fies interference.  The  treatment  which  fractures  ordinarily  require  is 
simply  rest,  cold  to  the  head,  saline  cathartics,  and  low  diet  for  many 
days.  Those  fractures  which  demand  especial  attention,  owing  to 
cerebral  complications,  are:  (1)  depressed  fractures,  simple  and  com- 
pound; if  the  simple,  depressed  fracture  is  without  symptoms  of  com- 
pression, do  not  interfere  with  it,  but  treat  the  case  as  one  of  concus- 
sion; if  the  symptoms  of  compression  are  present,  proceed  at  once  to 
raise  the  bone ;  if  the  compound  depressed  fracture  does  not  cause 
compression,  do  not  interfere  unless  there  are  evidences  by  the  probe 
that  sharp  fragments  are  driven  down  upon  the  meninges,  when  they 
should  be  very  cautiously  elevated,  or,  if  loose,  removed  to  prevent 
subsequent  inflammation;  (2)  penetrating  wounds  which  splinter  the 
internal  table;  the  danger  of  these  wounds  lies  in  the  subsequent  in- 
flammation which  the  bone  excites;  although  trephining  is  often 
practiced  as  a  preventive  measure,  the  results  are  not  favorable,  and 
the  wiser  course  is  not  to  interfere  unless  symptoms  of  irritation  or 
compression  supervene. 

II.    THE  SPINAL  CORD. 

Accidents  to  the  vertebral  column  derive  their  chief  importance 
from  endangering  the  spinal  cord;  certain  ])ortions  are  more  fre- 
quently the  seat  of  injury  than  others,  namely,  the  dorsi-lumbar,  the 
cervico-dorsal,  and  the  atlo-axial.-^ 

1.  Concussion  of  the  spine  often  develops  symptoms  of  the 
most  serious,  progressive,  and  persistent  character,  not  only  after 
apparently  slight  injuries,  but  frequently  when  there  is  no  sign  what- 
ever of  external  injuries. ^  It  occurs  usually  as  the  result  of  a  fall 
on  the  nates  or  back;  the  shock  is  generally  not  severe,  even  when 
the  paraplegic  condition  is  well  marked;  the  effects  maybe  imme- 
diate, or  may  not  supervene  for  some  time.^  In  direct,  severe  injury, 
the  primary  symptoms  vary  with  the  place  of  injury,  the  force,  and 
the  amount  of  organic  lesion  of  the  cord  produced;  a  blow  on  the 
upper  cervical  region  may  cause  instant  death,  and  on  the  dorsal  re- 
gion complete  paraplegia;  or  there  may  be  paralysis  of  motion,  loss 
of  power  over  the  sphincters,  alkaline  urine,  lowering  of  tempera- 
ture of  paralyzed  parts.  The  secondary  symptoms  are  usually  those 
of  development  of  inflammation  in  the  meninges;  namely,  pain  in 
some  part  or  parts  of  the  spine,  increased  by  pressure  and  motion, 
and  extending  around  the  body,  or  down  the  limbs.^  In  the  severest 
1  F.  Le  G.  Clarke.  2  a.  Sliaw.  3  j.  £.  Erichsen. 


INJURIES  OF  THE  NERVOUS  SYSTEM  279 

forms  there  are  lesions  which  give  rise  to  haemorrhage  w-ithin  the 
canal,  and  consequent  paralysis;  usually  the  blood  proceeds  from 
lacerations  of  the  venous  j)lexuses,  and  collects  on  the  outside  of  the 
cord  and  its  membranes,  and  in  largest  quantities  behind  and  at  the 
sides;  in  lesion  of  the  cord  itself  the  haemorrhage  is  slight,  owing  to 
the  small  size  of  its  vessels.  In  railway  injuries,  general  shock  is 
often,  but  not  always,  in  excess  of  that  which  accompanies  simple 
concussion;  the  collapse  may  be  great,  with  insensibility,  but  with- 
out evidence  of  injury  to  the  head;  other  sympioms  are  numbness 
and  tingling,  rigor,  continued  sickness,  excito-motor  spasm  in  the 
limbs,  violent  throbbing  sensations,  a  sense  of  heat  and  cold  in  the 
head  or  other  parts,  want  of  sleep  or  continued  drowsiness,  confusion 
of  intellect,  enfeebled  muscular  power,  deafness,  defective  sight  with 
ocular  spectra,  hypi'rajsihesia  in  some  parts,  especially  in  the  spine, 
great  emotional  excitability;  with  rare  exceptions,  there  is  extreme 
sensitiveness  of  the  spine,  more  frequently  located  at  some  particular 
part.^  In  some  cases  entire  recovery  follows  after  a  longer  or  shorter 
interval;  in  others  the  health  is  permanently  enfeebled,  and  a  life  of 
protracted  discomfort  is  entailed,  or  the  sufferer  sinks,  emaciated 
and  exhausted,  into  a  premature  grave,  or  becomes  the  victim  of  an 
acute  disease.^  The  early  treatment  must  be  complete  and  absolute 
rest  on  a  couch,  in  a  prone  position,  rather  than  the  supine,  to  avoid 
pressure  on  the  back  and  relieve  passive  venous  congestion,  with  dry 
cupping  on  either  side  of  the  vertebral  column,  and  ice-bags,  if  com- 
fortable; the  secondary  symptoms  must  be  treated  by  continued  rest 
and  such  counter-irritants  as  mustard  poultices,  stimulating  embro- 
cations, and,  finally,  setons  and  issues;  when  subacute  meningitis 
begins,  bichloride  of  mercury,  in  tincture  of  cinchona,  is  most  bene- 
ficial; at  advanced  periods  the  iodide  and  bromide  of  potassium, 
in  full  doses,  are  useful;  when  inflammation  has  subsided  and  par- 
alysis remains,  strychnine,  galvanism,  and  warm  salt-water  douches 
are  required. - 

2.  Tvrists,  sprains,  or  -wrenches  of  the  spine,  without  fracture 
or  dislocation  of  the  vertebras,  may  occur  in  a  variety  of  ways.* 
They  usually  result  from  violent  bending  and  twisting  of  the  column, 
and  the  force  is  chiefly  expended  on  the  joints  and  their  ligaments; 
in  the  cervical  and  lumbar  regions  the  impulse  is  broken  and  dis- 
persed, owing  to  their  mobility  and  elasticity;  while  in  the  dorsal 
region  they  have  the  character  of  a  jar  or  jolt,  owing  to  its  rigidity.' 
They  are  most  liable  to  occur  in  the  more  moiiile  parts  of  the  col- 
umn, as  the  neck  and  loins,  ami  less  fretjuently  in  the  dorsal  region; 
the  head  is  frequently  forcibly  thrown  forwards  and  backwards,  mov- 
ing as  it  were  by  its  own  weight,   the   patient  having  momentarily 

1  F.  Le  G.  Clarke. •  2  j.  e.  i:,ichsen.  8  A.  Shaw. 


280  OPERATIVE  SURGERY. 

lost  control  over  the  muscles  of  the  neck  ;  the  lumbar  spine  is  often 
strained,  with  or  without  similar  injury  to  the  cervical  portion  of  the 
column  ;  the  pain  closeh'  resembles  that  met  with  in  any  joint  after 
a  severe  wrench  of  its  ligamentous  structures,  but  is  peculiarly  dis- 
tressing in  the  spine,  owing  to  the  extent  to  which  fibrous  tissue  and 
ligament  enter  into  the  composition  of  the  column;  there  is  aching 
pain  in  the  articulations,  greatly  increased  on  pressure  and  motion  of 
any  kind  to  and  fro,  and  especially  by  rotation  ;  the  spine  is  rigidly 
inflexible,  the  patient  being  unal)le  to  stoop. ^  If  the  sprain  has  lacer- 
ated the  membranes  of  the  cord,  extravasation  of  blood  follows,  with 
gradually  increasing  paralysis. ^  The  recovery  depends  upon  (1)  the 
extent  of  stretching  of  muscles  and  ligaments;  (2)  the  extension  of 
the  inflammation  excited  in  and  about  the  articulations  to  the  inte- 
rior of  the  spinal  canal;  (3)  the  immediate  injury  to  the  cord  and  its 
coverings.  In  the  most  favorable  cases  recovery  may  be  complete  in 
a  few  weeks  or  months.  But  it  often  happens  that  the  apparently 
slight  injuries  finally  become  serious,  and  hence  the  occurrence  of  a 
lengthened  interval  between  the  infliction  of  the  injury  and  the  de- 
velopment of  spinal  symptoms  is  unfavorable,  as  it  indicates  pro- 
gressive structural  change.^  If  the  vertebral  column  is  so  weakened 
as  to  require  artificial  support  for  several  months  to  enable  it  to  main- 
tain the  weight  of  the  head,  it  will  probably  never  regain  its  normal 
strength  and  power  of  support.^  When  extravasation  of  blood 
takes  place  from  the  rupture  of  vessels  without  other  injury  of  the 
cord,  absorption  may  in  time  be  so  complete  as  to  i-elieve  the  par- 
alysis. The  hopeless  cases  are  those  in  which  chronic  inflammation 
has  gone  on  to  the  development  of  atrophy,  softening,  or  other  struc- 
tural changes,  of  the  substance  of  the  cord.^  The  treatment  must 
depend  upon  the  conditions  observed  in  each  case,  but  in  general 
the  remedial  measures  are  the  same  as  in  concussion;  namely,  long- 
continued  rest  and  efforts  to  prevent  or  subdue  inflammation. 

3.  Fractures  of  the  spine  ^  derive  their  chief  importance  from 
their  relations  to  injuries  of  the  cord.  Wherever  the  column  is 
broken  from  the  occijnit  to  the  second  lumbar  vertebra  where  the 
medulla  spinalis  terminates,  the  cord  partakes  of  the  injury,  and  all 
of  the  body  below  the  fracture  at  once  loses,  more  or  less  completely, 
both  motor  power  and  sensation,  and  hence  the  higher  in  the  spine 
the  fracture  occurs  the  graver  will  be  the  consequences;  owing  to  the 
small  size  of  the  medulla,  both  the  motor  and  sensory  tracts  of  the 
cord  are  generally  deprived  of  their  functions  simultaneously;  the  ex- 
tent of  the  injury  to  the  cord  may  vary  from  the  slightest  lesion  to 
a  complete  rupture,  the  degree  depending  upon  the  violence  applied. 
When  the  cord  is  severely  injured  the  symptoms  are  those  of  general 
1  J.  E.  Erichseu.  •  2  A.  Shaw. 


INJURIES  OF  THE  NERVOUS  SYSTEM.  281 

shock  to  the  norvoiis  system;  at  first  there  is  profouml  collapse;  on 
recovery,  pain  is  severe  at  tlie  seat  of  injury,  especially  on  motion; 
there  are  irregular  projections  and  depressions  in  the  processes  of 
the  vertebra";  paralysis  of  the  whole  body  below  the  level  of  the 
fracture;  the  urinary  bladder  becomes  distended  from  paralvsis  of  the 
muscles;  the  faeces  are  retained,  or  pass  involuntarilv.  These  svmp- 
toms  will  be  modified,  according  to  the  locality  of  the  fracture,  as  fol- 
lows: below  the  second  lumbar  vertebra  there  may  be  an  absence  of 
paralysis  and  complete  recovery;  between  the  second  lumbar  and 
tenth  dorsal,  the  paralysis  is  more  often  partial,  motor  power  beinf 
lost  while  sensation  remains,  and  recovery  is  very  frequent;  between 
the  tenth  and  fourth  dorsal  the  cord  is  more  likely  to  be  crushed 
through  its  whole  thickness,  owing  to  its  small  size,  followed  bv  im- 
perfect respiration,  complete  para[ilegia,  finally,  bed-sores  and  ex- 
haustion; between  the  second  dorsal  and  fifth  cervical,  the  cord  will 
more  likely  be  crushed  and  broken  down  in  its  substance  than  com- 
pressed, the  body  below  is  paralyzed,  the  respiration  becomes  more 
and  more  embarrassed,  through  paralysis  of  the  intercostal  and  ab- 
dominal muscles,  and  death  ensues  in  five  to  eight  davs;  if  at  the 
fifth  or  fourth  cervical,  the  upper  extremities  are  included  in  the  pa- 
ralysis, and  death  may  be  expected  within  a  few  hours;  if  the  frac- 
ture occur  above  the  level  of  the  fourth  cervical,  with  crushing  of  the 
cord,  instant  death  will  ensue,  as  the  function  of  the  phrenic  nerve 
is  destroyi'd.  The  treatment  should  at  first  aim  to  protect  the  cord 
from  further  injury;  guard  against  motion  of  the  spine  in  transporta- 
tion by  placing  the  patient  on  a  firm  support,  as  a  door  or  shutter  ; 
if  the  neck  is  fractured,  steady  the  head  by  sand-bags;  cut  off  the 
clothes,  ami  if  there  is  much  projection,  gently  stretch  the  body,  as 
but  slight  change  in  the  position  of  the  patient  is  all  that  is  needed, 
and  when  laid  flat  on  his  back  the  parts  tend  of  themselves  to  come 
into  correct  apposition;  the  bed  should  be  selected  with  a  view  to 
protect  the  back  and  hips  from  undue  pressure,  and  prevent  all  mo- 
tion of  the  spine;  the  water-bed  is  the  best,  and  next,  a  narrow,  low 
one,  with  boards  instead  of  sacking,  and  two  or  more  elastic,  yet 
firm,  horse-hair  mattresses,  covered  by  rubber  cloth;  provision  may 
be  made  to  allow  the  escape  of  urine  and  faeces  into  a  receptacle 
under  the  bed  by  the  use  of  rubber  drawers,  having  a  tube  passinor 
through  the  bed  lo  the  vessel  below;  ^  draw  off  the  water  with  a  full 
sized  catheter,  and  repeat  the  operation  twice  daily,  washinir  out  the 
bladder  with  tepid  water  slightly  acidulated  with  nitric  acid  ;  the 
greatest  care  should  be  taken  to  prevent  bed-sores  by  keepiuir  the 
bed  dry  aiul  relieving  jiressure  by  pillows,  pads,  and  rujs  for  the 
hips;   if  they  form,  they  must   be  cleansed  with  carbolic  solutions, 

1  Bradley. 


282  OPERATIVE  SURGERY. 

and  protected  from  all  irritants;  such  remedies  as  leeching  and  tre- 
phining the  spine  are  to  be  discarded.  If  convalescence  follows,  it 
will  be  protracte<l,  and  may  often  be  aided  by  a  suitable  apparatus.^ 

III.    THE  NERVES. 

Nerves,  like  other  tissues,  are  subject  to  lesions  from  physical 
agencies,  which  may  act  without  breaking  the  skin,  simple  lesions, 
or  may  involve  the  integument;  the  latter  nerve  wound  is  less  grave 
than  the  former.^ 

1.  Contusion  of  nerves  '^  is  a  common  incident  of  civil  practice  ; 
as  a  rule,  a  blow  with  any  blunt  instrument  over  the  length  of  a 
nerve  is  unlikely  to  be  serious;  but  in  the  same  injury  to  a  nerve  at 
its  exit  from  a  bony  foramen,  or  where  it  rests  in  a  furrow  of  bone, 
or  lies  superficially  on  the  prominence  of  a  joint,  the  consequences 
may  be  much  more  severe  ;  a  frequent  cause  of  contusion  of  nerves 
is  the  dislocation  and  reduction  of  bones,  especially  at  the  shoulder- 
joint,  where  the  nerves  are  liable  to  be  bruised  by  being  pressed  be- 
tween the  head  of  the  humerus,  the  first  rib,  and  clavicle.  When 
violent  contusions  do  not  cause  immediate  symptoms  of  loss  of  func- 
tion, numbness  and  tingling  may  succeed  to  the  first  shock  of  pain, 
and  only  after  a  time  be  replaced  by  grave  troubles,  due  to  changes 
in  the  bruised  nerve.  When  contusion  is  followed  in  a  few  days  by 
slight  numbness  and  prickling  associated  with  growing  tenderness 
over  the  nerve  track,  pi-ompt  treatment  is  necessary,  as  there  is  a 
commencing  neuritis,  or  of  a  sclerotic  state  which  may  or  may  not  be 
of  inflammatory  origin ;  the  nerve  may  sometimes  be  felt  in  thin  per- 
sons as  a  firm  cord;  in  some  cases  the  evil  is  most  insidious,  and 
may  result  in  large  functional  losses  without  any  notable  j)ain  or 
tenderness.  Tlie  proper  treatment  for  a  contused  nerve  is  absolute 
rest,  with  the  use  of  leeches  and  cold  water  when  symptoms  of  neu- 
ritis are  {iresent;  apply  three  or  four  leeches  twice  weekly  along  the 
nerve,  and  cold  continuously,  unless  disagreeable  to  the  patient;  in- 
ject morphia  if  the  pain  is  severe;  later,  opium  plaster  along  the 
nerve  is  useful,  and  if  pain  is  intermittent  give  quinine  or  arsenic. 

2.  Compression  of  nerves-  by  external  and  internal  causes  is 
frequent,  as  by  cicatrices,  callus,  tumors,  parturition,  faecal  accumu- 
lations, malposition  during  sleep,  use  of  a  crutch;  the  effect  of  pres- 
sure upon  a  nerve  is  to  disturb  the  contents  of  the  nerve  tubes  in 
such  manner  that  impressions  are  no  longer  conveyed  until  the 
pressure  is  removed  and  the  continuity  of  the  contents  of  the  nerve 
tube  is  restored.  The  symptoms  are,  (1)  delusive  impressions,  as 
formication,  prickling,  sense  of  warmth;  (2)  a  seeming  return  to 
the  normal  condition  and  feelings;   (3)  hyperEesthesia.  all  the  func- 

1  E.  D.  Hudson.  2  s.  W.  Mitchell. 


DISEASES   OF  THE  NERVOUS  SYSTEM.  283 

tions  exaltLHl,  muscular  power  unchanged  ;  (4)  anesthesia  and  mus- 
cular palsy,  preceded  by  a  sense  of  roughness  of  the  skin,  burnin"-, 
muscular  weariness,  vague  cramps.  When  the  pressure  is  removed 
recovery  takes  place  in  a  reverse  order;  (1)  there  is  first  pain,  tick- 
ling, sensibility;  (2)  sudden  sense  of  cold  and  feeling  of  enormous 
weight;  (3)  awkward  motions,  with  formication;  (4)  regular  mo- 
tions and  sense  of  heat.  'J'he  treatment  consists  in  removinir  the 
cause,  and  meeting  the  iullammatury  symptoms  with  the  remedies 
directed  in  ca>es  of  contusion. 

3.  Wounds  of  nerves  ^  may  be  incised  or  punctured.  The  incised 
wound  is  causeil  by  severe  cuts,  as  with  a  knife,  or  glass.  It  is  of 
great  importance  to  make  out  first  the  extent  of  injury,  and  this  may 
be  done  by  examining  as  to  the  local  paralysis.  If  the  nerve  is  par- 
tially divided,  cleanse  the  wound  of  all  foreign  matter  with  carbolic 
solutions;  close  it  with  sutures  or  adhesive  strip;  place  the  limb  in  a 
position  to  relax  the  tissues  and  approximate  the  cut  ends  ;  enjoin 
perfect  rest;  apply  cold.  Where  it  is  plain  that  the  nerve  trunk  has 
been  altogether  divided,  the  silver  wire  suture  may  be  used  to  ai)prox- 
imate  the  extremities;  it  should  be  inserted  near  the  cut  surfaces, 
or  through  the  loose  tissue  related  to  its  sheath;  the  wound  should 
then  be  accurately  closed;  the  restoration  of  function  takes  place 
only  after  long  periods.  Punctured  wounds  of  small  branches  are 
more  serious  than  of  large  trunks;  they  follow  the  use  of  the  lancet 
as  in  venesection  and  vaccination,  or  other  penetrating  instrunnnts. 
The  symptoms  are  acute  pain  in  the  track  of  the  nerve  immediately 
or  very  soon,  gradually  increasing  in  severity  until  spasms  or  convul- 
sions occur;  slight  injinies  of  the  digital  nerves  seem  especially  prone 
to  occasion  distressing.'  symptoms,  and  wide-spread  reflex  sympathies. 
The  treatment  is  complete  division  if  practicable;  rest  and  cold  to 
prevent  inflammation;  hypod«>rmic  injections  of  morphia  to  relieve 
pain. 

CHAPTER   XXV. 

DISEASES   OF  THE   NERVOUS   SYSTEM   AND    SPECIAL 
OPERATIONS. 

I.  THE  HRAIN. 
1.  Inflammation  ^  w^ithin  the  cranium  may  follow  any  injury  to 
the  head;  tin- brain  alniu-  may  l)e  invDlved,  or  the  membranes,  and 
even  the  bone.  Inflammatory  softening  is  rarely  met  with  in  tlie 
central  white  portions  of  the  brain,  but  tlie  cortical  substance  is  fre- 
quently inflamed,  as  the  result  of  injury  to  the  bone,  and  meningitis, 
1  S.  W.  Mitchell.  2  P.  Hewett. 


284  OPERATIVE  SURGERY. 

Avbich  supervenes  after  concussion  ;  the  intlamed  gray  matter  becomes 
of  a  dark-red  hue,  is  swollen  and  soft;  effusion  takes  place  in  the 
pia  mater,  and  the  gray  matter  becomes  of  a  darker  color  and  dif- 
fluent; this  softening  is  frequently  very  extensive,  the  white  matter 
remaining  unaffected.  There  are  two  kinds  of  traumatic  inflamma- 
tion of  the  membranes;  one  commences  in  the  dura  mater  and  almost 
always  reaches  the  free  surfaces  of  the  arachnoid;  the  other,  com- 
mencing in  the  pia  mater,  seldom  passes  beyond  this  membrane  un- 
less the  inflammation  is  very  severe.  When  the  inflammation  spreads 
inwards  from  an  injury  of  bone  or  of  its  coverings,  its  progress  may 
be  traced,  as  it  were,  layer  by  layer,  from  the  outer  parts  down  to 
the  brain,  involving  fir<t  the  dura  mater,  then  the  parietal  and  vis- 
ceral arachnoid,  the  pia  mater,  and  ultimately  the  cortical  substance 
of  the  brain.  In  suppuration  of  the  bone  the  outer  surface  of  the 
dui'a  mater  is  covered  with  lymph  or  pus,  its  tissue  becomes  infiltrated, 
and  sloughing  may  follow ;  the  mischief  is  generally  confined  to  that 
part  of  the  membrane  directly  under  the  <liseased  bone,  but  it  may 
spread  along  the  cellular  tissue  around  the  meningeal  arteries,  and 
thus  reach  even  to  the  base  of  the  skull.  When  this  inflammation 
reaches  the  arachnoid  it  becomes  wide-spread,  and  the  cavity  of  this 
membrane  becomes  filled  with  a  puriform  exudation  of  a  yellowish- 
green  color,  extending  sometimes  over  one  and  occasionally  over 
both  hemispheres,  but  not  to  the  base.  From  the  arachnoid  the  in- 
flammation spreads  to  the  pia  mater,  where  it  is  followed  by  a  simi- 
lar exudation,  llie  cortical  substance  corresponding  to  the  inflamed 
pia  mater,  is  often  of  a  dark  leaden  hue,  soft  and  easily  torn  ;  the 
white  substance  is  simply  congested.  Tlie  symptoms  of  traumatic 
intercranial  inflammation  are  progressive,  as  follows:  (1)  Pain  in 
the  head,  more  or  less  intense,  confined  to  the  seat  of  injury  or 
spreading  over  the  whole  head,  fever,  contraction  of  pupils,  intoler- 
ance of  light  and  sound;  (2)  disturbance  of  the  brain-functions, 
restlessness,  constant  tossing  about,  convulsions,  delirium;  (3)  drow- 
siness, oscillation  and  dilatation  of  pupils,  twitchings  and  spasms  of 
muscles,  coma,  relaxation  of  sphincters,  paralysis;  (4)  rigors,  indica- 
tive of  suppuration.  It  cannot,  however,  be  accurately  decided  what 
tissues  are  involved  in  the  inflammatory  process,  nor  whether  pus 
has  formed.  The  treatment  should  be  decided  upon  after  examining 
the  different  viscera,  especially  the  kidneys;  in  general,  secure  rest 
and  quiet  in  a  dark  room  ;  shave  the  head,  elevate  it,  and  apply  ice 
or  the  cold  douche  ;  give  repeatedly  saline  purgatives;  venesection  is 
very  rarely  required,  but  leeching  the  temples  is  often  useful;  blisters 
may  be  applied  in  late  stages;  bromide  of  potassa  in  twenty  to 
forty  grain  doses  may  be  necessary  to  secure  quiet  and  sleep ;  opium 
should  not  be  sriven  unless  other  anodvnes  fail. 


DISEASES   OF   THE  NERVOUS  SYSTEM.  285 

2.  Abscess  of  the  brain  follows  injury,  either  from  an  inflamma- 
tion excited  by  the  increased  vascularity  of  the  tissues  and  the  ab- 
sence of  any  escape  lor  disorganized  tissue  and  the  superfluous  prod- 
ucts of  the  re])arative  process,  or  by  tlie  penetration  of  the  inflam- 
mation from  the  external  injury  throuj^h  the  intervening  tissues  ;  in 
the  former  case  the  abscess  forms  in  the  interior  of  the  brain,  and  in 
the  latter  between  the  bone  and  dura  mater.^  The  formation  of  pus 
is  usually,  but  not  invariably,  indicated  by  a  well-marked  shivering 
fit,  in  intercranial  inflammation;  coma  or  compression  may  not  follow, 
as  brain  abscess  is  usually  devoid  of  any  new  element  in  its  ingre- 
dients,^ but  if  the  pus  is  between  the  bone  and  dura  mater,  symp- 
toms of  compression  generally  appear.  The  treatment  when  abscess 
is  declared,  as  by  symptoms  of  compression,  is  trephining;  the  point 
of  operation  should  be  the  seat  of  previous  injury,  which  may  be 
marked  by  a  puffy  swelling  of  the  scalp  ;  when  the  bone  is  perforated, 
if  pus  is  not  found,  and  the  dura  mater  bulges  into  the  hole,  giving 
evidence  of  the  existence  of  pus  beneath  this  membrane,  divide  the 
dura  mater ;  if  pus  is  still  not  discovered  and  there  is  good  reason  for 
believing  that  a  cerebral  abscess  exists  under,  or  in  the  neighborhood 
of,  the  part  perforated,  the  brain  may  be  punctin-ed  or  incised.^ 

3.  Hernia  cerebri  is  the  protrusion  of  brain  matter,  or  the  prod- 
ucts of  inflammation,  through  openings  in  the  bone  and  meninges; 
it  may  follow  fractures  or  trephining.  It  is  mainly  due  to  inflamma- 
tion of  the  brain  and  to  the  effusion  of  serum  and  pus ;  the  cerebral 
substance  around  the  place  of  protrusion  is  congested,  swollen,  cedeni- 
atous,  and  soft;  abscesses  frequently  form  in  the  hemisphere  in- 
volved, and  large  effusions  of  various  kinds  fill  the  ventricles  ;  the 
mass  rises  out  of  the  opening  like  a  mushroom,  and  often  partially 
sloughs  away.  It  may  terminate  in  recovery,  gradually  wasting 
away,  but  in  the  majority  of  cases  the  patient  sinks  sooner  or  later. 
The  treatment  is  that  of  an  inflammation:  remove  all  sources  of  irri- 
tation: secure  rest  and  quiet;  preserve  perfect  cleanliness  by  syring- 
ing with  weak,  cold  carbolic  solutions  ;  dust  the  dry  surface  with 
oxide  of  zinc  or  alum;  severe  pressure,  caustics,  and  the  knife  are 
injurious. 

4.  Hydrocephalus  is  an  effusion  of  fluid  internal  or  external  to 
the  ventricles,  and  may  be  congenital  or  acquired  ;  the  former  being 
due  to  malformation,  the  latter,  to  meningeal  inflammations.  In  the 
congenital  form,  well  marked,  the  effusion  is  into  the  ventricles  ;  as 
the  fluid  increases  the  pressure  from  within  gradually  unfolds  the  con- 
volutions, and  thus  expands  the  cranial  arch;  the  base  may  undergo 
little  change,  but  the  frontal,  parietal,  and  occipital  bones  are  ex- 
panded in  all  directions,  and  become  much  thinner;  the  hemispheres 

1  F.  LeG.  Clarke.  2  \y,  Detmold;  P.  Hewett;  L.  Holden. 


286  OPERATIVE  SURGERY. 

are  spread  out  in  thin  laminae  on  eitlier  side,  decreasing  in  thick- 
ness from  the  base  to  the  vertex:  the  membranes  do  not  usually  iin- 
der<ifo  any  alteration  except  such  as  arise  from  distention.  If  the  eyes 
have  a  persistent  and  characteristic  downward  direction,  it  is  due  to 
a  change  in  the  orbital  plates  of  the  frontal  bone.  In  the  acquired 
form,  the  effusion  is  over  the  surface  of  the  brain,  in  the  subarach- 
noid spaces,  or  in  the  lateral  ventricles ;  it  generally  comes  on  after 
consolidation  of  the  bones,  but  may  appear  very  early  and  assume 
the  conditions  of  the  congenital  variety.  Operative  interference  is 
of  two  kinds,  namely:  compression  and  tapping.  They  are  opposite 
measures,  and  adapted  to  different  and  opposite  conditions  of  the 
brain;  the  one  repairs  defect  of  pressure,  the  other  relieves  its  ex- 
cess; either  t'xpedient  may  suffice  alone;  both  may  be  profitably  em- 
ployed in  the  same  case  in  succession,  according  to  varying  circum- 
stances; if  the  walls  of  the  head  are  tight  and  firm,  the  trocar  should 
precede  the  blindage;  if  lax  and  movable,  compression  should  be 
cautiously  tried,  and  followed,  if  need  be,  by  the  puncture.^  Com- 
pression should  be  employed  as  follows:  Cut  strips  of  adhesive  or 
rubber  plaster  one  third  of  an  inch  in  width ;  apply  first  one  strip 
from  each  mastoid  process  to  the  outer  part  of  the  orbit  on  the  op- 
posite side ;  then  from  the  back  of  the  neck  along  the  longitudinal 
sinus  to  the  root  of  the  nose;  next  over  the  whole  head  so  that  the 
strips  cross  each  other  at  the  vertex;  finally,  pass  a  long  strip  three 
times  around  the  head,  just  above  the  ears,  eyebrows,  and  below  the 
occipital  protuberance;  avoid  making  the  dressing  too  tight,  lest  con- 
vulsions should  be  excited;  if  the  health  is  good  and  the  cap  is  toler- 
ated it  must  be  continued,  but  if  the  increase  of  fluid  threatens  con- 
vulsions it  must  be  loosened  or  removed  in  a  few  days.  If  tapping 
is  necessary,  proceed  as  follows:  Select  a  small  aspirating  needle,  or 
a  small  ti'ocar,  if  the  aspirator  is  not  used;  holding  it  perpendicu- 
larly, insert  it  at  the  edge  of  the  anterior  fontanelle  to  avoid  the 
longitudinal  sinus  and  the  large  veins  emptying  into  it;  withdraw 
the  fluid  verv  slowly,  meantime  maintaining  moderate  external  com- 
pression by  the  hands  of  an  assistant,  or  a  bandage;  not  more  than 
two  or  three  ounces  should  be  drawn  at  once,  and  if  the  pulse  be- 
comes weak,  or  the  dilated  pupils  contract,  or  there  are  signs  of  con- 
vulsions, the  needle  or  canula  must  be  withdrawn,  and  the  puncture 
hermetically  closed.  To  maintain  proper  compression,  a  cap  may 
be  in  readiness,  made  of  sheet  caoutchouc,  and  perforated  with  small 
holes. 

5.   Meningocele  ^  (Fig.  233)  consists  of  a  protrusion  of  the  menin- 
ges of  the  brain  by  an  accumulation  of  fluid  within  the  cranium  of 
the  new-born  infant;  the  tumor  appears  at  one  of  the  foetal  open- 
1  T.  Watson.  2  t.  Holmes. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  287 

ings  of  the  I)onos,  and  is  caused  by  a  preexisting  liydroceplialiis;  the 
ordinary  situation  is  in  the  occipital  region,  and  the  tumor  protrudes 
through  tlie  expaiicU'd  portion  of  the 
occipital  bone,  behind  the  foramen 
magnum,  and  in  the  middle  line;  oc- 
casionally this  tumor  ap[tears  at  other 
points,  especially  at  either  fontanelle, 
and  at  the  root  of  the  nose  ;  it  has 
been  found  at  the  sides  of  the  skull 
where  the  bones  are  joined,  at  the 
inner  angle  of  the  orbit,  above  the 
orbital  arch,  in  ihe  temporal  region, 
at  the  base  of  the  skull  communicating  Fig.  233. 

with  the  deep  parts  of  the  face.  The  tumor  may  be  a  single  sac, 
or  have  numerous  septa;  it  may  be  sessile  or  have  a  pedicle;  it  may- 
be translucent  like  a  hydrocele  and  enlarge  when  the  child  cries; 
or  be  i-educible.  The  nature  of  the  tumor  is  recognized  by  these 
appearances,  and  by  its  being  congenital.  The  dangers  of  inter- 
ference with  these  tumors  lies  in  their  relations  to  the  meninges 
and  the  brain.  In  treatment  avoid  all  irritating  external  applica- 
tions. As  a  rule,  nothing  ought  to  be  done  but  to  support  the  tumor 
and  make  gentle  pressure  with  a  bandage,  or  cap,  protected  with 
cotton  wool  to  prevent  ulceration,  as  gutta  percha  lined  with  layers 
of  wadding  which  can  be  gradually  increased  in  number  as  the 
tumor  yields  to  pressure;  if  it  is  on  the  increase  without  other  symp- 
toms, repeated  puncture  may  be  tried,  the  air  being  excluded;  if  the 
tumor  has  a  pedicle,  iodine  maybe  injected,  using  3ij  with  ecpial 
parts  of  water,  after  some  of  the  fluid  has  been  removed.  Excision 
should  be  ))racticed  when  the  communication  of  the  tumor  with  the 
brain  is  obliterated;  if  the  operation  is  undertaken  while  there  is 
still  an  opening  into  the  cerebral  cavity,  the  pedicle  should  be  em- 
braced by  a  clamp,  and  flaps  should  be  made  so  as  to  perfectly  cover 
the  wound  when  united  by  the  continuous  suture;  the  damp  should 
be  retained  twenty-four  hours  or  more  to  preserve  proper  contact  of 
the  opposed  surfaces  ;  antiseptic  spray  should  be  used  during  the 
operation. 

6.  Encephalocele  resembles  meningocele,  but  its  contents  consist 
of  a  protniiling  portion  of  brain,  or  of  brain  and  dropsical  mem- 
branes ;  it  a])pi'ars  at  the  various  openings  of  the  skull,  and  may  be 
sessile  or  ])e(liinculated ;  it  is  recognized  as  a  congenital  tumor,  often 
pulsating,  generally  small  and  flat;  it  is  most  difhcult  of  diagnosis 
when  seated  at  the  root  of  the  nose,  in  the  course  of  the  frontal 
suture,  or  near  one  of  the  angles  of  the  orbit,  as  it  resembles  sel)a- 
ceous  or  other  tumors;   in  cases  of  doubt,  the  effects  of  pressure 


288 


OPERATIVE  SURGERY. 


Fig.  234. 


upon  the  growth  must  be  carefully  noted,  and  the  examination 
should  be  several  times  repeated;  it  is  justifiable  to  use  an  exploring 
needle.     The  treatment  is  that  of  meningocele. 

II.  THE  SPINAL  CORD. 
1.  Spina  bifida  (Fig.  234)  is  a  congenital  defect  in  the  bones  of 
the  spinal  column,  which  admit!<  the  protrusion  of  the  meml)ranes  in 
the  form  of  a  hernia;  it  is  of  the  same  nature  as  a 
meningocele,  and  contains  subarachnoid  fluid,  and 
n  often  nerve  trunks,  and  even  the  spinal  cord  itself  ; 
.-^  hydrocephalus  often  exists  at  the  same  time;  the 
defect  may  exist  at  any  point  in  the  column,  cervi- 
cal, dorsal,  lumbar,  or  sacral,  but  the  lumbo-sacral 
form  is  most  frequent ;  the  tumor  may  have  a  broad 
or  very  narrow  base,  and  directly  open  into  the  spinal 
canal,  or  be  quite  disconnected;  its  coverings  may 
be  quite  thick,  or  so  thin  as  to  be  transparent,  or 
ulcerated  so  as  to  allow  the  escape  of  its  contents  ; 
it  is  usually  quite  tense  when  the  child  is  awake 
and  erect.  In  general  this  affection  proves  fatal,  sometimes  owing 
to  the  defective  organization  of  the  child,  in  other  cases  from 
convulsions,  or  an  inflammation  following  an  opening  of  the  sac. 
No  case  of  spina  bifida  ought  ever  to  be  sul)jected  to  any  active 
operative  interference,  except  in  the  most  urgent  circumstances,  and 
the  mildest  measure  which  affords  any  rational  prospect  of  cure 
should  be  the  one  selected.*  It  may  be  treated  by  punctures  with 
needles  and  compression,  the  punctures  being  at  the  side  to  avoid 
nervous  tissue;  by  injections  of  iodine,  as  follows:  draw  off  several 
ounces,  then  inject  five  grains  iodine,  and  fifteen  grains  of  iodide 
of  potassium  dissolved  in  an  ounce  of  water  ;  after  a  few  seconds, 
allow  this  fluid  to  tiow  out,  wash  the  sac  with  water,  and  inject  two 
ounces  of  the  original  cerebro-spinal  fluid  ;  ^  by  pressure  around  the 
neck  of  the  sac  to  bring  the  internal  surfaces  in  contact  and  secure 
adhesions  and  thus  shut  off  the  cavity  of  the  tumor  from  the  spinal 
canal,  and  admit  of  its  excision  ;  by  excision,  when  there  is  no  ner- 
vous tissue  in  the  sac,  and  the  pedicle  is  small,  after  applying  a 
clamp  several  days  and  thus  exciting  new  action  in  the  sac  ;  ^  or  if 
the  base  is  broad  dissecting  the  soft  parts  from  the  sac,  opening  it 
by  free  incision  on  one  side,  removing  a  portion,  but  reserving  a  flap 
to  be  attached  to  the  root  of  the  pedicle  on  the  other  side  of  the 
opening  into  the  spinal  canal  ;  i  by  evacuation  of  the  contents  of  the 
sac,  pushing  its  collapsed  parietes  back  into  the  canal,  and  uniting 
the  soft  parts  over  all  sufficiently  tight  to  prevent  protrusion.* 

1  T.  Holmes.  2  d.  Braiuard.  3  Wilson.  *  B.  Chase. 


DISEASES   OF  THE  XERVOUS  SYSTEM.  289' 

III.     TEIE  NERVES. 

1.  Inflammation,^  acute,  attacks,  by  preference,  the  nerves  of 
robust  j)ersons  and  of  adults;  its  seat  is  the  neurilenuua  and  the 
connective  tissue  between  the  bundles  of  fibres;  the  chanires  are 
due  to  deranged  nutrition,  and  the  nerve  varies  from  a  pale  rose  to 
a  deep  reil  color,  and  there  is  a  variable  increase  in  the  diameter,  its 
component  bundles  bein^  separated  from  each  other.  The  symptoms 
are  a  tearing,  darting,  lancinating  pain  along  the  course  of  the  nerve 
trunk  with  a  sensation  of  tingling,  formication,  or  numbness;  it  never 
becomes  suddenly  severe,  nor  ceases  suddenly,  like  neuralgia,  but  is 
continuous,  though  variable  in  severity;  is  always  aggravated  by 
pressure  and  by  the  contraction  of  muscles.  The  chronic  form  may 
result  from  the  acute,  or  be  a  continuation  of  a  mild  attack,  and  is 
a  frequent  cause  of  certain  kinds  of  neuralgia,  neuroma,  and  pain- 
ful subcutaneous  tubercle.  The  treatment  of  the  acute  form  is  the 
local  abstraction  of  blood,  evaporating  lotions  or  anodyne  fomenta- 
tions, and  opiates  to  relieve  pain. 

2.  Ulceration  of  nerves  ^  occurs  in  the  neighborhood  of  ulcers, 
and  cau>es  protracted  suifering;  the  surrounding  parts  are  often  en- 
larged, the  skin  increases  in  thickness,  the  muscles  and  tendons 
ulcerate.  The  treatment  is,  ointment  of  well-powdered  opium,  or 
opium  in  water;  if  remedies  fail,  excise  the  nerves  as  far  as  pos- 
sible from  the  ulcer;  it  is  also  advisable  to  divide  the  nerve  as  near 
the  upper  part  of  the  wound  as  possiljle. 

3.  Painful  subcutaneous  tubercles  ^  are  spherical,  or  oval,  or 
fusiform  tumors,  generally  white,  always  firm,  sometimes  hard,  hav- 
ing a  fibrous  or  fibro-cartilaginous  structure;  the  size  varies  from 
that  of  a  millet  seed  to  that  of  a  pea;  they  are  situated  in  the  sub- 
cutaneous areolar  tissue,  embedded  between  the  fibres  of  nerves 
which  are  separated  and  stretched  over  them;  they  cause  the  most 
acute  pains,  which  dart  like  electric  shocks  along  the  course  of  the 
nerve.  Pain  recurs  very  irregularly,  and  lasts  from  ten  minutes  to 
two  hours  or  more;  it  begins  gradually,  increases  in  intensity,  and 
gradually  decreases,  leaving  the  tubercle  and  parts  around  more  or 
less  tender;  in  all  cases  of  obstinate  neuralgia  of  the  extremities, 
search  should  be  made  for  these  tubercles.  The  only  treatment  is 
extirpation. 

4.  Neuromata  ^  are  larger  than  subcutaneous  tubercles,  but  mav 
be  of  every  size,  from  a  small  grain  of  wheat  to  a  larije  melon;  thev 
are  round,  oblong,  oval,  or  fusiform,  and  when  superficial,  movable 
only  laterally;  they  are  situated  between  the  neurilemma  and  nerves, 
or  in  the  connective  tissue  between  the  bundles  of  nerves;  they  con- 

1  J.  L.  Clarke. 
19 


290  OPERATIVE  SURGERY. 

sist  for  the  mo«t  part  of  tough  and  wavy  fibrous  tissue  with  a  varia- 
ble number  of  nuclei  and  small  cells.  When  they  are  numerous 
there  is  little  or  no  pain,  but  a  solitary  neuroma  is  a  source  of  the 
most  violent  agony,  which  shoots  along  the  nerve  like  electric  shocks. 
Thev  frequently  occur  in  stumps  after  amputation,  rendering  the 
limb  both  painful  and  intolerant  of  pressure.  The  only  successful 
treatment  is  removal,  either  by  excision  of  the  tumor  and  a  portion 
of  the  nerve,  or  by  amputation  of  the  limb. 

5.  Neuralgia^  from  nerve  injury  may  depend  upon  pressure  or 
the  presence  of  foreign  bodies,  but  more  often  it  is  a  question  as  to 
whether  the  nerve  is  in  a  state  of  inflammation  or  sclerosis.  If  the 
former  conditions  exist,  relief  may  be  easy,  as  by  removing  the  local 
cause.  If  the  nerve  is  inflamed,  repeated  leeching  and  the  steady 
application  of  dry  cold  for  a  week  or  two  are  the  best  remedies;  if 
cold  cannot  be  borne  hot  poultices  should  be  applied.  The  pains  of 
traumatic  neuralgia  can  only  be  satisfactorily  relieved  by  narcotic 
hypodermic  injections;  the  salts  of  morphia  are  to  be  preferred  to 
all  others;  the  fourth  of  a  grain  may  be  given  and  increased  if  neces- 
sary ;  if  it  is  desired  to  maintain  the  anresthetic  power  of  morphia 
without  the  hypnotic  effect,  add  atropia,  thus:  to  half  a  grain  of  sulph. 
of  morphia  add  one  thirtieth  of  a  grain  of  sul[)h.  of  atropia.  The 
alveolar  processes  sometimes  undergo  thickening  and  condensation 
after  the  removal  of  the  permanent  teeth,  which  causes  such  com- 
pression of  the  dental  nerves  that  severe  and  persistent  neuralgia 
results.  The  relief  from  this  affection  is  most  readily  and  effectually 
secured  by  removing  the  diseased  process.^  Make  an  incision  along 
the  ridge  of  the  process ;  separate  the  periosteum  from  the  bone  by 
means  of  the  elevator;  with  rectangular  gnawing  forceps  remove 
the  process  to  its  entii'e  depth  ;  allow  the  parts  to  heal  by  the  falling 
together  of  the  surfaces  of  the  wound.  Dissection  of  nerve  from 
the  condensed  cicatricial  tissue  following  a  gunshot  wound  has  been 
performed^  with  success,  as  follows:  the  median  nerve  was  enclosed 
in  a  dense  cicatrix  at  the  middle  of  the  arm,  involving  the  biceps 
muscle,  resulting  from  a  gunshot  wound  ;  the  nerve  was  gradually 
laid  bare  and  dissticted  out,  so  that  it  lay  perfecth^  loose  in  the 
wound  for  an  inch  and  a  half  or  two  inches  of  its  length;  the  wound 
was  lightly  dressed,  and  allowed  to  heal;  neuralgia  returned  slightly, 
with  cicatrization,  but  eventually  disappeared  altogether.  In  ex- 
treme cases,  amputation  of  parts  is  occasionally  practiced.  Now 
that  it  is  possible  to  prevent  the  reunion  of  nerves,  amputation  offers 
no  advantages  over  resection  of  the  nerve  at  some  higher  point;  it  can, 
therefore,  never  be  justified,  except  where  more  than  one  nerve  is 
involved,  or  where  the  limb  has  been  rendered  altogether  useless  by 
grave  injury.^ 

1  S.  W.  Mitchell.  •-!  .J.  M.  Warren ;  S.  D.  Gross.  3  j.  M.  Warren. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.       291 

III.     THE  NERVOUS   CONSTITUTION. 

Neuromimesis,!  nervous  mimicry,  should  be  duly  considered  in 
the  dia<;nosis  of  sur<;ieal  affections,  for  there  is  scarcely  a  local  or- 
cranic  disease  of  invisible  structures  which  may  not  be  mimicked  by 
nervous  disorder.  Examples  are  freciuent  in  the  more  or  less  acute 
inllammalions  of  the  joints,  especially  of  the  knee  and  hip;  it  im- 
itates diseases  of  the  spine,  paraplegia,  tetanus,  aphonia,  deform- 
ities, aneurism,  and  tumors.  It  may  be  regarded  as  a  localized 
manifestation  of  a  certain  constitution,  but  as  to  what  is  the  pe- 
culiarity of  the  nervous  constitution  there  is  no  positive  knowledge; 
it  may  be  stated  that  the  nervolis  centres  are  too  alert,  too  highly 
charged  with  nerve  force,  two  swift  in  mutual  influence,  too  deli- 
cately adjusted  or  defectively  balanced,  but  these  expressions  may 
be  misguiding,  and  it  is  better  to  study  the  nervous  constitution  in 
clinical  facts.  In  the  great  majority  of  cases  there  is  either  history 
or  present  evidence  of  a  characteristic  nervous  constitution;  some 
have  been  or  are  truly  hysterical,  but  very  many  have  never  been 
hysterical.  The  means  for  diagnosis  are  to  be  sought  (I)  in  the 
general  condition  of  the  nervous  system  on  which,  as  on  a  predis- 
posing constitution,  the  nervous  mimicry  is  founded;  (2)  in  the 
events  by  which,  as  by  exciting  causes,  the  mimicrj'  may  be  evoked 
or  localized;  (3)  in  the  local  symptoms  of  each  case.  The  treat- 
ment is  too  varied  to  notice  in  detail,  but  must  be  directed  against 
(1)  the  local  symptoms;  (2)  the  constitutional  condition  which  may 
co-exist  or  be  combined  with  the  nervous;  (3)  the  nervous  constitu- 
tion itself. 

CHAPTER  XXVI. 
GENERAL  OPERATIONS   ON  THE  NERVOUS   SYSTEM. 

I.    THE  BRAIN. 

Trephining  the  cranium  should  be  regarded  as  an  operation 
always  fraught  with  danger,'-  and  only  to  be  performed  from  clear 
necessity.  The  following  general  rules*  should  guide  in  deciding 
the  question:  (1)  In  diffused  injiuies  to  the  cranium  and  its  contents 
all  operative  interference  is  unjustifiable;  (2)  in  simple  fractures, 
with  or  without  depression,  and  in  compound  fractures  that  are  not 
comminuted,  with  or  without  dej)ression,  operative  interference  is 
only  called  for  when  marked  and  persistent  symptoms  of  local  com- 
pression of  the  brain  exist;  (3)  in  compound  comminuted  fractures, 
with  or  without  brain  symptoms,  depressed  bone  should  be  elevated 

1  Sir  J.  Paget.  2  j.  Le  G.  Clarke.  3  T.  Bryaut. 


292 


OPERATIVE  SURGERY. 


and  fragments  removed,  witli  the  oliject  of  taking  away  known 
sources  of  irritation  to  tlie  membranes  and  common  causes  of  enceph- 
alitis; (4)  in  all  cases  of  local  injury  to  the  cranium,  of  fracture  or 
other  injury,  followed  by  clear  clinical  evidence  of  local  inflammation 
of  the  bone,  and  persistent  symptoms  of  brain  irritation,  or  subosteal 
suppuration,  the  operation  should  be  undertaken.  Proceed  as  fol- 
lows: Shave  the  scalp  at  the  point  where  the  oi)eration  is  to  be  per- 
formed; place  the  head  upon  a  firm  pillow;  give  an  anaesthetic 
when  the  patient  is  fully  conscious;  select  the  point  of  application  of 
the  crown  of  the  trephine  so  as  to  avoid  the  main  branc.-hes  of  the 
middle  meningeal  artery  (Fig.  235),  and  the  longitudinal  and  other 
sinuses;    make   an    incision   down   to   the   bone,   having   the   form 

V,  -\--i  or  other  shape,  as  may  be 
necessary  to  expose  the  bone;  care- 
fully raise  the  pericranium  over 
a  s])ace  just  sufficient  to  admit  the 
trephine;  if  at  any  point  the  ele- 
vator can  be  introdut-ed  sufficiently 
to  raise  the  fragment  without  using 
the  trephine,  elevate  the  depressed 
bone  very  cautiously,  until  its  mar- 
gin is  on  a  level  with  the  sound 
Fig.  235.  bone;  if  this  is  impracticable,  place 

the  pin  upon  the  margin  of  the  sound  bone,  and  taking  the  handle  in 
the  right  hand  move  it  alternately  to  the  right  and  left,  until  the 
teeth  have  cut  a  groove  sufficiently  deep  to  re- 
ceive them  ;  the  perforator  is  then  loosened  and 
slid  up  in  the  shaft  and  fixed,  to  avoid  wounding 
the  membranes ;  great  care  should  be  taken  to 
maintain  the  instrument  in  a  position  perpendicu- 
lar to  the  part  operated  upon  (Fig.  23 G),  in  order  to 
avoid  its  penetrating  more 
deeply  on  one  side  than 
the  other,  and  thus  sud- 
denly wounding  the  cere- 
FiG.  236.  bral  membranes;  examine 
the  depth  of  the  groove  frequently  to  ascertain  how  nearly  the  in- 
strument has  completed  the  section  of  the  bone, 
\//^^^y^~-^3^  occasionally  cleaning  the  teeth  with  a  small 
brush  or  wet  sponge;  raise  the  disc  of  bone 
with  the  elevator  (Fig.  237).  In  fractures 
with  depression  there  are  frequently  projecting 
points  of  bone  which  it  is  desirable  to  remove;  this  may  be  done 
with  the  bone  nippers  (Fig.  238).     If  there  is  a  blood  clot,  remove 


Fig.  237. 


Fig.  238. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.       293 

it  with  care,  lost  blccdiiifr  recur;  if  the  nienin;T(.al  artory  is  exposed 
and  Ijleods,  compress  it  with  a  piece  of  spou'je,  clotli,  or  wood  in- 
serted under  the  niarixin  of  tlie  Ijone ;  if  the  blood  or  pus  producing 
com])ression  are  lielow  the  dnra  mater,  open  it  sulHcientlv  to  remove 
these  matters.  The  conical  trephine  is  to  be  preferred  in  all  cases 
where  the  bone  is  thin. 

ir.     THE  SPINAL  CORD. 
Trephining  the   spinal  column  to  relieve  compression  of  the 
cord,  whether  froiii  (K'pres^ed  hone  or  extravasated  blood,  is  now  re- 
garded as  a  useless  operation. ^ 

III.  THE  NERVES. 
Neurotomy,  the  section  of  a  nerve;  neurectomy,  the  resection  of 
a  portion  of  a  nerve  ;  and  stretching  of  a  nerve,  are  operations  un- 
dertaken for  the  relief  of  pain,  and  of  spasm.  These  operations  are 
justifiable  only  as  a  last  resort,  all  other  measures  having  failed. ^ 
Section  of  a  nerve  should  always  be  made  at  a  point  which  will  in- 
volve as  few  terminal  branches  as  possible,  and  yet  the  division  must 
be  sufHciently  high  to  include  all  of  the  affected  trunk,  for  if  dis- 
eased tissue  is  left  above  the  line  of  division  the  subacute  neuritis 
and  sclerosis  may  continue  to  ascend  the  nerve  and  render  the  op- 
eration useless;  it  is  important  that  the  area  of  the  painful  region 
should  be  accurately  determined,  and  the  trunk  carefully  examined 
for  enlargements  and  hardness  by  rolling  the  nerve  under  the  finder; 
as  a  rule  the  section  should  be  a  short  distance  above  the  point  at 
which  the  nerve  ceases  to  feel  enlarged  and  hard;  if  it  is  practicable 
to  find  a  spot,  even  a  little  farther  up  the  limb,  where  the  nerve  is 
neither  swollen  nor  tender,  select  that  point;  when  the  nerve  lies 
too  deep  for  examination,  especially  if  the  neuralgia  is  of  long  stand- 
ing and  of  traumatic  origin,  operate  as  near  the  body  as  possible;  if 
the  neuralgic  cause  is  purely  local,  a  healthy  point  is  found.*  But 
neurotomy,  or  simple  division  of  a  nerve,  is  at  present  scarcely  ever 
practiced,  owing  to  the  certainty  of  prompt  reunion ;  resection  is 
necessary  and  not  less  than  two  inches  of  its  length  ought  to  be  re- 
moved, the  object  being  to  make  reunion  impossible,  or  very  remote 
in  point  of  time;  in  addition  it  is  well  to  turn  the  peripheral  extrem- 
ity back,  and  if  necessary  secure  it  with  a  loop  of  wire,  or  even  in- 
terpose muscle  or  fascia  to  prevent  the  possibility  of  union. *  Ex- 
posure and  stretching  of  spinal  nerves  as  a  final  resort  for  the  relief 
of  spasms*  is  now  recognized  as  a  justifiable  operation.  Tt  orior- 
inated  in  the  exposure,  isolation,  and  rul)])ing  of  the  sciatic  nerve  ^ 

1  J.  Ashmst,  Jr.       ■!  S.  AV.  Mitchell;  W.  A.  Ilammoiul;  E.  Brown-Sequard. 

3  S.  W.  Mitchell.  *  Von  Nussbauin.  6  x.  Bilhoth. 


294 


OPERATIVE  SURGERY. 


from  a  point  below  the  gluteal  fold,  through  the  sciatic  foramen,  to 
the  sacral  foramen,  for  the  purpose  of  relieving  epilepsy  supjjosed  to 
be  due  to  some  irritating  cause  affecting  the  nerve.  No  such  cause 
was  found,  but  the  stretching  Avhich  tlie  nerve  received  relieved  the 
spasms.  It  is  beheved  that  the  manipulation  produces  a  favorable 
chano-e  in  the  position  of  the  nerve  fibres  in  the  trunk,  whereby  their 
nutrition  is  improved.  The  procedure  is  essentially  the  same  as 
that  of  dissecting  a  similarly  affected  nerve  out  of  cicatricial  tissue  ^ 
long  since  successfully  practiced.  The  operation  consists  in  exposing 
the  nerve  and  stretching  it  with  fingers,  forceps,  or  blunt  hooks,  as 
if  attempting  to  draw  it  from  its  connection  to  the  spinal  cord. 

NERVES   OF  THE  HEAD,  FACE,  AND  NECK. 

1.  The  supra-orbital  nerve  (Fig.  239)  is  a  terminal  branch  of 
the  frontal,  b,  a  portion  of  the  first  division  of  the  fifth  cranial  nerve, 

a  ;  it  runs  along  the  roof  of  the  or- 
bit, passes  out  through  the  supra- 
orbital foramen,  and  ascends  upon 
the  forehead.  It  should  be  di- 
vided as  it  emerges  from  the  fo- 
ramen, and  before  branches  are 
given  off.  Section  is  made  as  fol- 
lows, 1  (Fig.  239)  :  Recognize  the 
supra-orbital  notch,  or  foramen; 
pass  the  tenotome  subcutaneously 
from  a  point  two  or  three  lines 
on  the  inner  side  of  the  notch 
outward  beyond  the  notch;  turn 
the  blade  backwards  and  cut 
down  to  the  bone.  Resection  is 
made  as  follows:  make  an  incision  an  inch  in  length  down  to  the  bone, 
just  above  the  notch;  seize  the  cut  ends  of  the  nerve  in  the  Avound 
and  remove  it  to  the  desired  extent.  Or  the  brow  m;iy  be  raised 
and  the  lid  depressed,  and  the  incision  be  made  along  the  edge  of 
the  border  of  the  orbit;  the  nerve  is  seized  in  the  wound  and  re- 
secteil;  tlie  wound  will  fall  under  the  brow  Avhen  the  skin  is  relaxed. 

2.  The  infra-orbital  nerves  are  the  terminal  branches  of  the  su- 
perior maxillary  nerve  as  it  emerges  from  the  infra-orbital  foramen, 
beneath  the  elevator  muscle  of  the  upper  lip,  and  consist  of  palpe- 
bral, nasal,  and  labial  sets.^  The  focus  of  pain  is  at  the  origin  of 
these  nerves.3  Section  may  be  made  through  the  mouth  as  follows: 
recognize  the  infra-orbital  foramen,  2  (Fig.  239)  above  the  second  bi- 
cus[)id  tooth  and  nearly  half  an  inch  below  the  margin  of  the  orbit; 

1  J.  M.  Warren.  2  Quaiu's  Anatomy.  "  Valleix. 


Fig.  2.39. 


OPERATIONS  ON  THE  NERVOUS  SYSTEAf.       295 

raising  the  upper  lip,  make  an  incision  along  the  fold  of  junction  of 
the  lip  and  maxilla,  ami  (.onlinue  the  dissection  to  the  upper  limits 
of  the  fossa  :  now  take  straight  scissors,  and  continue  the  dissection 
upwards  to  the  infra-oibital  foramen,  which  is  four  or  five  lines  be- 
low the  orl.it  in  the  direction  of  the  first  molar  tooth;  the  nerves  are 
readilv  divided  as  they  emerge  from  the  canal.  Section  through  the 
skin  is  made  thus  :  the  patient's  head  being  elevated  and  turned  to 
the  other  side,  recognize  the  exact  position  of  the  foramen  by  the 
guides  given,  and  make  an  incision  directly  upon  it  through  the 
skin  and  fascia. 

3.  The  superior  maxillary  uerve,  c  (Fig  2ot)),  is  the  second 
branch  of  the  fifth;  it  passes  through  the  foramen  rotundum,  across 
the  spheno-maxillary  fossa,  and  traverses  the  infra-orbital  canal  in 
the  floor  of  the  orbit  and  terminates  at  its  foramen.  Section  is  made 
with  a  strong  tenotome  carried  along  the  floor  of  the  orbit  in  the 
direction  of  the  nerve  ;  at  a  depth  of  two  thirds  of  an  inch  cut 
across  the  floor  of  tlie  orbit,  which  is  thin,  severing  the  nerve  at  3.^ 
Resection  may  at  the  same  time  be  made  by  a  transverse  incision,  one 
third  of  an  inch  below  the  border  of  the  orbit,  exposing  the  nerve, 
which  may  be  seized  and  drawn  out  of  the  canal. ^  In  the  more 
formal  operations  the  external  incisions  may  take  various  forms,  as 
V,  -|-,  U,  H,  the  centre  being  the  foramen;  the  object  is  to  fully  ex- 
pose the  foramen,  and  the  margin  of  the  orbit;  the  canal  may  be 
entered  by  the  trephine  applied  to  the  antrum, ^  or  by  raising  the 
tissues  covering  the  floor  of  the  orbit,  and  entering  the  posterior  part 
where  the  canal  is  covered  by  fibrous  structures.  The  trephine  is 
required  when  the  nerve  is  removed  at  4  (Fig.  239),  the  foramen  ro- 
tundum ;3  the  crown  should  be  j^mall  and  be  so  placed  as  to  open  the 
antrum  at  the  canal  ;  the  lower  wall  of  the  canal  is  broken  with  the 
chisel  to  the  sphenomaxillary  fossa;  the  dissection  may  now  be  car- 
ried on,  and  the  nerve  divided  at  the  foramen  rotundum  with  scis- 
sors curved  on  the  (lat.  The  canal  may  be  opened  by  raising  the 
soft  parts  from  the  floor  of  the  orbit  an  inch  or  more  from  the  orb- 
ital edge,  and  with  a  hook  set  at  right  angles  with  its  shaft,  the 
nerve  may  be  raised  and  excised  an  inch.*  The  latter  method  is  to 
be  preferred  when  the  resection  is  confined  to  the  portion  of  nerve 
in  the  canal. 

4.  The  Ungual,  or  gustatory,  nerve, /(Fig.  239),  one  of  the  spe- 
cial nerves  of  the  taste,  su])plies  the  mucous  membrane  of  the  mouth, 
the  gums,  the  sublingual  gland,  and  the  papilla;  and  mucous  mem- 
brane of  the  tongue;  it  is  one  of  the  posterior  branches  of  the  inferior 
maxillary  branch  of  the  lifth  nerve;  it  is  deeply  placed,  lying  first  be- 
neath the  external  pterygoid  muscle  to  the  inner  side  of  the  inferior 
1  J.  V.  MaL'aiiTue.       '^  J.  M.  Carnotliau.       3  J.  K.  Wood.       *  T.  G.  Murton. 


296  OPERATIVE  SURGERY. 

dental,  then  between  the  internal  pterygoid  and  the  inner  side  of  the 
ramus  of  the  ja<v,  and  crosses  to  the  side  of  the  tongue  beneath  the 
stylo-glossus  muscle.  Resection  is  made  where  the  nerve  lies  upon 
the  ramus,  6  (Fig.  239),  thus:  the  mouth  opened  widely,  recognize  the 
pterygo-maxillary  ligament  below  the  attachments  of  which  the  nerve 
may  be  felt  on  the  inner  side  of  the  jaw;  make  an  incision  backward 
from  the  molar  tooth  over  the  nerve,  an  inch  in  length;  the  nerve  will 
appear  in  the  wound,  and  may  be  picked  up  and  resected;  or,  draw 
out  the  tongue  to  the  opposite  side,  and  make  an  incision  over  the  sub- 
lingual gland,  e  (Fig.  239),  continue  the  dissection  through  the  upper 
edge  of  the  gland,  when  the  nerve  will  be  exposed  and  may  be  excised.^ 

5.  The  inferior  dental  nerve,  d  (Fig.  239),  is  a  branch  of  the 
inferior  maxillary  ;  it  accompanies  the  inferior  dental  artery  beneath 
the  external  pterygoid  between  the  internal  lateral  ligament  and 
the  ramus  of  the  jaw,  to  the  dental  foramen,  along  the  dental  canal 
in  the  maxillary  bone,  beneath  the  teeth,  to  the  mental  foramen. 
Resection  may  be  intrabuccal,  or  by  external  incision.  The  intra- 
buccal  operation  is  as  follows  :  -  the  corner  of  the  mouth  being  held 
wide  open,  make  an  incision  about  one  inch  long,  obliquely  from 
within  outwards,  along  the  anterior  border  of  the  ramus  of  the  jaw 
through  the  anterior  fibres  of  the  internal  pterygoid  muscle;  tear 
through  the  connective  tissue  between  the  pterygoid  and  the  peri- 
osteum with  the  finger,  when  the  nerve  is  easily  reached  at  its  en- 
trance into  the  dental  canal.  Resection  by  external  incision  may  be 
made  at  any  point  of  the  course  of  the  nerve.  If  the  trunk  is  to  be 
removed  before  the  nerve  enters  the  canal,  5  (Fig.  239),  make  an  in- 
cision from  the  sigmoid  notch  down  to  the  edge  of  the  jaw,  raise  and 
turn  back  the  parotid  gland,  dissect  up  the  lower  portion  of  the  mas- 
seter  muscle,  and  remove  a  section  of  bone  with  the  trephine ;  half 
an  inch  of  the  nerve  is  exposed  for  resection;  the  dental  artery  is 
liable  to  be  cut,  but  may  be  ligated.^  Resection  of  any  portion  of 
the  nerve  in  the  canal  may  be  effected  by  raising  a  flap,  exposing 
the  bone,  and  applying  the  trephine  once,  twice,  or  more,  and  re- 
moving the  external  wall  of  the  canal. ^  Or,  the  trephine  may  be 
applied  at  two  different  points,  the  nerve  trunk  cut  in  them,  and 
that  portion  then  be  extracted.^  The  terminal  portion  of  the  in- 
ferior dental,  as  it  emerges  from  the  mental  foramen,  7  (Fig.  239),  is 
distributed  to  the  integument  of  the  chin  and  lower  lip.  Resection 
is  made  at  the  foramen  thus:  Evert  the  lower  lip,  and  make  an  in- 
cision down  to  the  bone  where  the  lip  and  gum  unite  along  the 
groove  which  separates  the  alveoli  of  the  canine  and  first  molar 
teeth;  the  ends  of  the  divided  nerve  appear  in  the  wound;  seize  the 
pro.ximal  end  with  forceps  an<l  draw  out  of  the  canal  as  much  as 
possible. 

1  J.  Hilton.     2  Paravicini.     3  j.  M.  Warren.     *  S.  D.  Gross.     5  c.  Sedillot. 


OPERATIONS  ON  THE   NERVOUS  SYSTEM.       297 

6.  The  facial  nerve,  H  (Fi'^.  239)  eiiierjri-s  from  tlie  craninin  at 
the  slylo  mastoid  foramen,  ami  passing  throu'jih  the  parotid  f;Iand 
divides  into  tlie  temi)oio-facial  and  cervieo-facial  branches.  Sootion 
of  the  nerve  trunk  may  be  made  at  the  stylo-mastoid  foramen  as  fol- 
lows: Make  an  ineisiim  vertically  two  inches  in  len<^th  alon'^  the  an- 
terior border  of  the  process,  and  of  tlie  sterno-mastoid  muscle  ;  draw 
the  parotid  gland  strongly  forwards  and  dissect  with  the  handle  of 
the  scalpel  to  a  depth  varying  from  a  half  to  three  fourths  of  an 
inch,  when  the  nerve  will  be  found  crossing  the  wound;  the  internal 
jugular  vein  is  within  a  quarter  of  an  inch  of  the  foramen,  and  in 
the  direction  of  the  wound.  The  temporal  branch  may  be  divided 
where  it  crosses  the  condyle,  by  an  incision  sli'.ditly  oblique  from 
before  backwards,  starting  from  the  zygomatic  arch  and  terminating 
above  the  posterior  border  of  the  angle  of  the  jaw;  the  dissection 
should  be  continued  through  the  connective  tissue,  the  parotid  gland 
being  drawn  down  when  exposed;  the  nerve  will  be  found  close  to 
the  bone  and  separated  from  it  by  connective  tissue. 


NKUVK.S    OK    THE    UPPER    LIMB. 

The  nerves  of  the  upper  limb  requiring  section  are  branches  of 
the  brachial  plexus,  which  is  composed  of  the  four  lower  cervical 
and  first  dorsal  nerves. 

1.  The  brachial  plexus  may  require  resection  when  the  neuralgic 
condition  involves  a  large  num- 
ber of  branches.  The  part 
most  favorably  situated  for  re- 
section is  the  first  coml)ination 
of  nerves  in  the  two  cords. 
These  nerves  lie  above  and  to 
the  outer  side  of  the  sul)clavian 
artery,  and  external  to  the  sca- 
lenus anticus  muscle.  Operate 
as  follows:  1  Elevate  the  shoul- 
ders, drop  the  head  backwards 
with  the  face  strongly  inclined 
to  the  sound  side;  this  renders 
the  tissues  of  the  affecteil  side 
tense,  and  makes  prominent 
the  sterno-cleido-mastoid,  the 
landmark  for  the  first  incision; 
an  assistant  makes  the  external 
jugular  pr(jmiiicnt  by  comfires- 


FiG.  240. 


sing  it  with  a  finger  ap|)lied  over  the  uppir  marg'in  of  the  clavicle  at 

its  middle,  or  on  a  line  drawn  from  the  angle  of  the  jaw  to  the  middle 

1  II.  B.  SaiuLs  F.  F.  Maury. 


298 


OPERATIVE  SURGERY. 


of  the  clavicle;  make  an  incision  downwards  along  the  external  bor- 
der of  the  sterno  cleido-iuastoid  beginning-  three  inches  above  the 
clavicle  ;  from  this  point  make  a  second  incision  along  the  course  of 
the  clavicle,  giving  an  L  form  to  the  incisions  of  the  integnmcnt;  the 
length  of  both  imnsioivs  must  be  regulated  by  the  size  of  the  neck  of 
the  patient;  the  next  important  guide  is  the  tendon  of  the  omo-hyoid 
muscle,  which  must  be  searched  for  with  the  finger  and  handle  of  the 
scalpel,  the  external  jugular  vein  being  drawn  aside;  the  posterior 
belly  of  the  omo-hyoid  being  recognized  is  held  aside  by  the  finger 
or  ligature  ;  the  two  cords  of  the  plexus  now  appear;  place  a  liga- 
ture loosely  around  the  upper  cord  by  means  of  the  aneurism  needle, 
or  hold  it  aside  with  a  blunt  hook  (Fig.  240);  pass  the  index  finger 
of  the  left  hand  into  the  wound  and  ascertain  the  exact  position  of 
the  subclavian  artery,  which  is  to  be  held  out  of  the  way  and  carefully 
protected;  now  divide  the  cord  as  near  the  finger  of  the  left  hand  as 
possible,  with  blunt  pointed  scissors,  and  make  a  second  division 
above  the  point  of  section,  as  far  up  as  practicable,  care  being  taken 
not  to  interfere  with  the  scalenus  anticus  muscle  across  which  passes 
the  phrenic  nerve;  four  fifths  of  an  inch  of  the  cord  may  be  removed, 
and  the  cut  ends  by  retraction  separated  two  and  a  quai'ter  inches. 
The  outer  cord  is  next  resected  to  the  requisite  extent.  The  outer 
cord  may  be  cut  first,  and  then  the  inner,  by  carefully  protecting  the 

subclavian  artery,  as  it  lies  in  im- 
mediate proximity  with  the  latter 

cord. 

2.  The  external,  or  musculo- 
cutaneous nerve,  1   (Fig.   241) 

rises  from  the  outer  cord   of  the 

brachial  ple.Kus,  passes  oliliqiiely 

between  the  biceps  and  brachialis 

anticus  to  the  outer  side  of  arm, 

then   becomes   cutaneous,   and  is 

distributed   to  the  integument  of 

the   radial    border   of    the    arm. 

Recognizing  the  space  above  the 

elbow,  between  the  biceps  and  the 

anterior   border  of  the  supinator 

radii  longus,  make  an  incision  two 

inches    in    length,    oblique    from 

above  downwards,   and  from  be- 
hind forwards;   divide    the    skin, 

fascia,   and  aponeurosis,   and  the 
nerve  will  be  pxj)i)se'd,  and  may  be  resected  to  the  required  extent. 
3.  The  internal  cutaneous  nerve,  2  (Fig.  241)  is  a  branch  of 


Fig.  241. 


Fig.  242. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.        299 

the  internal  cord,  ami  is  distributed  to  the  internal  portions  of  the 
forearm.  Make  an  incision  obliquely  from  the  lower  part  of  the 
biceps  downward  and  inward  to  a  point  an  inch  below  the  internal 
condyle  ;  cut  only  lhroui;h  the  skin,  then  open  the  connective  tissue, 
in  which  the  nerve  will  i)e  found. 

4.  The  musculo-spiral  nerve,  1  (Fig.  242),  is  the  largest  branch 
of  the  brachial  plexus,  and  is  distributed  to  the  muscles  and  skin  of 
the  posterior  surface  of  the  arm.  forearm,  and  hand;  it  winds  around 
the  arm  in  a  groove,  with  the  superior  profuinla  artery,  passing  from 
the  inner  to  the  outer  side  of  the  bone,  beneath  the  triceps  muscle; 
it  descends  between  the  brachialis  anticus  and  supinator  longus  to 
the  front  of  the  e.xternal  condyle,  where  it  divides  into  the  radial 
and  ])Osterior  interosseous.^  Resection  is  made  above  the  external 
condyle  as  follows  :  Make  an  incision  three  inches  in  length  along 
the  external  border  of  the  triceps  muscle,  and  between  it  and  the 
brachialis  anticus.  Commencing  three  inches  above  the  external 
condyle,  and  in  line  with  it,  dissect  the  connective  tissue  with  the 
handle  of  the  scalpel;  the  nerve  is  readily  exposed  close  to  the  bone, 
and  may  be  resected  to  any  necessary  extent.  Or  the  nerve  may  be 
exposed  above  and  internal  to  the  external  condyle,  by  recognizing 
the  space  between  the  supinator  longus  and  the  brachialis  anticus, 
and  making  an  incision  two  and  a  half  inches  long. 

i)  The  median  nerve,  3  (Fig.  241),  has  been  excised  for  neural- 
gia in  the  lower  part  of  the  forearm  below  the  oris^ins  of  the  mus- 
cular and  anterior  interosseous  branches,  and  above  the  origin  of 
the  palmar  cutaneous  branch.^  Ascertain  precisely  the  margins  of 
the  flexor  carpi  radialis  and  palmaris  longus  muscles  by  extending 
the  hand  upon  the  forearm;  make  an  oblique  incision  two  and  a  half 
inches  long  from  over  the  border  of  the  first  to  that  of  the  last-named 
muscle,  the  lower  end  of  the  incision  terminating  two  inches  above 
the  line  of  the  wrist  joint;  divide  the  superficial  fascia  and  muscular 
aponeurosis  on  a  director;  seek  the  nerve  in  the  intermuscular  space, 
and  expose  it  at  the  lower  end  of  the  cut,  where  it  emerges  from  be- 
neath the  oblicpie  fleshy  fibres  of  the  flexor  sublimis  digitorum;  raise 
this  nuiscle  and  the  nerve  will  be  ex[)Osed  the  length  of  the  cut. 

6.  The  radial  and  ulnar  nerves  may  be  resected  by  the  same 
operative  piocedures  as  are  taken  in  ligature  of  the  respective  ar- 
teries which  they  accompany,  4,  5  (Fig.  241). 

7.  The  digital  nerves^  may  be  excised  by  an  incision  on  the  inner 
or  outer  aspect  of  the  first  phalanx  of  the  finger;  in  severe  cases  of 
nein-algia,  resection  should  be  performed  on  both  sides  of  the  linger; 
subcutaneous  section  of  these  nerves  may  be  made  by  passing  a  nar- 
row-bladed  knife  on  both  siiles. 

1  H.  Gray.  2  J.  H.  Briaton.  s  J.  M.  Warren. 


300 


OPERATIVE  SURGERY. 


NEUVF.S    OF    THE    LOWER    LIMB. 

The  nerves  of  the  lower  hnib  requiring  section  are  branches  of 
the  kimbar  and  sacral  plexus. 

1.  The  great  sciatic,  5  (Fig.  243),  the  largest  nerve  of  the 
sacral  plexus,  supplies  largely  the  integument  of 
\  the  leg.  Place  the  patient  on  the  abdomen ;  rec- 
'  ognize  the  gluteal  fold,  and  the  point  of  junction 
of  the  flexor  muscles  of  the  thigh,  make  an  incision 
three  inches  long  through  the  skin,  fascia,  and  con- 
nective tissue ;  with  the  finger  and  handle  of  the 
scnlpel  expose  the  nerve,  and  resect  to  the  required 
extent.^ 

2.  The  popliteal  nerve,  3  (Fig.  243),  the  con- 
tinuation of  the  great  sciatic,  may  be  resected  at  the 
interval  between  the  flexor  muscles  above  the  pop- 
liteal space ;  the  incision  being  made  through  the 
skin  and  fascia,  the  nerve  should  be  uncovered  by 
dissection  with  the  finger  and  handle  of  the  scalpel, 
and  an  inch  and  a  half  removed. 

3.  The  perineal  nerve  is  the  larger  branch  of 
the  pudic;  it  is  distributed  to  the  organs  of  genera- 
tion. It  has  been  divided  for  severe  vaginal  neu- 
ralgia successfully, 2  as  follows:  With  the  finger  in- 
troduced deeply  into  the  vagina,  recognize  the 
nerve,  which  feels  as  a  hard  cord  and  is  very  sen- 
sitive on  pressure  ;  make  a  deep  vertical  incision, 
which  will  bring  the  nerve  into  view;  remove  it  to 

the  extent  of  an  inch. 

4.  The  small  sciatic  nerve,  4  (Fig.  243),  has  been  excised^  for 
nnilti|)Ie  neuroma  successfully,  as  nearly  as  possible  to  its  origin,  by 
an  obli(pie  incision  almost  in  the  direction  of  the  gluteal  fold;  the 
portion  of  nerve  Avas  removed  from  under  the  edge  of  the  gluteus 
maxinius. 

5.  The  peroneal  or  external  popliteal  nerve  is,  2  (Fig.  243) 
given  off  from  the  popliteal  nerve  and  passes  along  the  inner  margin 
of  the  tendon  of  the  biceps,  or  external  hamstring  muscle.  It  is 
excised  as  follows  :  Make  an  incision  two  to  three  inches  long,  on 
the  inner  border  of  the  biceps  tendon,  through  the  integument  and 
superficial  fascia;  the  nerve  will  be  found  close  to  the  tendon  and 
may  be  easily  excised  to  the  extent  of  an  inch  or  more. 

6.  The  anterior  and  posterior  tibial  nerves,  2  (Fig.  244),  6 
(Fig.  243)  accompany  their  res])ective  arteries  in  such  proximity 
that  the  incisions  for  the  ligature  of  these  arteries  may  be  adopted 
for  the  resection  of  the  nerves. 

i  T.  Billroth.  ^  T.  G.  Morton.  3  Kosinski. 


Fig.  243. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.       301 


7.  The  internal  saphenous  nerve,  1  (Fij^.  244),  is  a  branch 
of  the  anterior  crural  and  is  distributed  to  tlie  in- 
tenjiiment  on  the  inner  side  of  the  leuj;  it  hes  super- 
ficially in  immediate  relations  with  the  infernal  sa- 
phenous vein.  Make  an  incision  along  the  track 
of  tlie  vein  made  prominent  by  pressure  above;  the 
nerve  lies  immediately  behind  the  vein;  if  necessary, 
the  vein  may  also  be  divided  and  tied.  It  (3,  Fig. 
244)  may  also  be  resected  where  it  emerges  from  be- 
neath the  sartorius  muscle  at  the  inside  of  the  knee. 
Recognize  the  sartorius  and  gracilis  muscles  at  the 
inside  of  the  knee,  and  the  trunk  of  the  internal  sa- 
phenous vein  by  compressing  it  above ;  make  an 
incision  two  inches  long  in  the  course  of  the  vein 
through  the  skin  and  fascia,  draw  the  vein  aside, 
and  the  nerve  will  be  found  as  it  escapes  from  the 
deep  aponeurosis  and  may  be  resected  to  the  desired 
extent. 

8.  The  external  saphenous  nerve,  1  (Fig.  243), 
a  branch  of  the  lumbar  plexus,  descends  along  the 
fibular  side  of  the  posterior  surface  of  the  leg  in  con- 
nection with  the  vein  of  the  same  name.  Make  an 
incision  along  the  vein,  distended  by  pressure  above, 
behind  the  malleolus,  or  external  to  the  tendo- 
Achillis;  carefully  turn  the  vein  aside  and  the  nerve  will  be  exposed. 

9.  The  internal  plantar  nerve  has  been  successfully  resected^ 
for  tetnnns  caused  by  injuiy  of  the  digital  branches.  The  nerve 
is  the  larger  division  of  the  posterior  tibial  and  accompanies  the 
internal  plantar  artery ;  from  the  point  of  division  of  the  posterior 
tibial  nerve  between  the  internal  malleolus  and  heel,  it  is  directed 
forwards  under  cover  of  the  abductor  of  the  great  toe,  passing 
between  that  muscle  and  the  short  flexor  of  tlie  toes.  Make  an  in- 
cision along  the  internal  margin  of  the  foot,  commencing  at  the  an- 
terior border  of  the  heel  about  one  fourth  of  the  distance  from  the 
inner  to  the  outer  margin,  forwards  two  inches;  this  incision  will 
be  along  the  external  mai-gin  of  the  abductor  pollicis;  carefully 
open  the  space  between  this  abductor  and  the  short  flexor  and  the 
artery  will  be  recognized  with  the  nerve  accompanying  it,  which 
may  be  resected  an  inch  or  more. 

^  G.  E.  Foster. 


Fig.  244. 


VI. 

THE    TEGUMENTARY    SYSTEM. 

THE  SKIN;    THE    HAIR    AND    GLANDS;    THE   NAILS. 


CHAPTER  XXVII. 

INJURIES    OF   THE    TEGUMENTARY    SYSTEM  AND 
SPECIAL   OPERATIONS. 

I.    THE    SKIN. 

Though  the  skin  consists  of  several  separate  tissues,  as  the  epi- 
derms  and  papillary  body,  the  coriuni  and  subcutaneous  areolar  tis- 
sue, and  glands,^  they  are  all  so  implicated  in  injuries,  and  the 
various  results  which  follow,  that  they  cannot  practically  be  isolated. 

1.  Contusion  2  without  external  wound  is  the  common  bruise  of 
skin  and  subcutaneous  tissue,  and  may  be  of  various  degrees  of  se- 
verity; when  slight,  the  textures  suffer  only  shaking  or  jarring,  fol- 
lowed by  rupture  of  blood  vessels  and  effusion  of  fluid ;  in  severe 
contusions  the  damaged  structures  are  broken,  arid  there  may  be  visi- 
ble ruptures  of  soft  parts,  especially  splittings  of  the  subcutaneous 
tissue,  and  separations  of  it  from  the  fasciae;  in  extreme  cases  the 
parts  are  thoroughly  crushed.  Swelling  generally  quickly  follows 
the  violence  ;  first,  there  is  some  depression  or  indentation,  with  soft- 
ening of  the  injured  tissues:  swelling  succeeds,  due  partly  to  extrava- 
sation, but  much  more  to  the  rapid  afflux  of  blood  and  exudation 
from  the  vessels.  The  most  frequent  subcutaneous  haemorrhages  are 
from  the  veins;  if  the  extravasation  is  into  the  cutis  it  has  a  dark 
blue  color,  passing  into  brown;  if  it  escape  more  deeply  and  slowly, 
the  blood  forms  a  passage-way  between  the  connective  tissue  and 
muscles,  infiltrating  the  tissues  and  causing  swelling,  suggillation;  if 
much  blood  escape  suddenly  and  create  a  distinct  cavity,  it  forms  a 
blood-tumor,  ecchymosis,  or  haematoma. 

1  E.  Rindfleisch.  2  Sir  J.  Paget. 


INJURIES  OF  THE   TEGUMENT ARY  SYSTEM.    303 

The  colors  of  ordinary  recent  contusions  are  various  shades  of  purple  tending 
either  to  black  or  blue,  or  to  crimson,  or  pink;  and  with  tliese  are  n»in;;led 
shades  of  yellow,  pale  brown,  and  t;reeii,  dependent,  apparently,  on  the  quan- 
tity of  effused  serum  and  its  min^diu};  with  fluids  of  otlicr  colurs;  after  a  vari- 
able time  the  darker  colors  fade  out,  and  give  place  to  gradually  lightening 
shades  of  brownish  olive,  green,  and  yellow,  the  changes  commencing  at  the 
border. 

In  the  treatment,  when  the  effusion  is  going  on,  ice  may  he  applied, 
the  limb  or  part  being  suitably  elevated.  Simple  contusions,  left  to 
themselves  in  the  quietude  necessary  to  avoid  pain,  recover,  but  the 
process  may  be  hastened  by  stimulant  applications,  the  best  of  whiclj, 
except  for  persons  of  irritable  skins,  seems  to  be  tr.  arnica,  with 
equal  parts  of  water;  if  there  is  much  breaking  and  crushing  of  tissues 
the  parts  should  be  kept  warm  to  prevent  sloughing,  with  wrappings 
of  cotton-wool  soaked  in  oil,  or  linseed  poultices;  extreme  cases 
should  be  treated  as  for  traumatic  gangrene;  if  the  blood  remain  in 
large  quantities,  friction  and  kneading  may  promote  absorption  by 
diffusing  it  in  the  tissues;  if  it  still  remain,  evacuate  it  with  anti- 
septic precautions,  and  treat  the  cavity  as  an  open  abscess. 

2.  Incised  •wrounds  ^  are  made  with  sharp  instruments,  as  knives, 
sabres;  the  edges  are  smooth-cut,  regular,  the  tissue  unchanged. 
Pain  follows  tlie  injury  at  once,  varying  with  the  nerve  supply  of  the 
part  and  the  sensitiveness  of  the  patient ;  the  feeling  is  that  of  a 
peculiar  burning  or  smarting;  haemorrhage  is  the  second  immediate 
symptom,  its  extent  dependin'j;  upon  the  number,  size,  and  variety 
of  the  vessels  divided;  if  the  capillaries  alone  bleed,  the  ha?morrhage 
quickly  ceases;  if  an  artery  is  cut,  the  bright  red  blood  flows  in  a 
stream,  often  pulsatile;  haemorrhage  from  the  veins  is  characterized 
by  the  steady  flow  of  dark  blood. 

A  rapid,  excessive  loss  of  blood  induces  perceptible  changes  in  the  whole 
body;  the  face,  especially  the  lips,  becomes  pale  —  the  latter  bluish,  the  pulse 
is  smaller,  and  at  first  less  frequent :  the  bodily  temperature  sinks,  and  most 
perceptibly  in  the  extremities;  the  patient  faints  on  rising,  has  dizziness,  nau- 
sea, or  vomiting,  noises  in  the  ear,  and  everything  whirls  around;  he  becomes 
unconscious,  and  falls,  owing  to  rapid  ancemia  of  the  brain.  In  the  horizontal 
posture,  these  efifects  usually  soon  pass  off;  but  if  the  bleeding  continue  the 
countenance  grows  paler  and  waxy,  the  lips  pale  blue,  the  eyes  dull,  the  bodily 
tem|)erature  lower;  the  pulse  is  small,  thready,  and  very  frequent;  respiration 
is  incomplete;  the  patient  faints  repeated!^-,  constantly  grows  more  feeble  and 
anxious;  at  last  he  becomes  uncon.^cious;  there  is  twitching  of  the  arms  and  legs, 
renewed  by  the  slightest  irritation;  this  state  may  pass  into  death. 

The  treatment  of  an  incised  wound  demands,  first,  the  arrest  of 
hajinorrhage;  second,  perfect  (juiet  of  the  injured  part,  in  a  position 
to  diminish  the  flow  of  blood  to  and  through  the  part.     If  the  bleed- 
ing is  capillary,  it  will  usually  cease  on  exposure  of  the  wound  to  the 
1  T.  Billroth. 


304  OPERATIVE  SURGERY. 

air,  or  the  application  of  cold,  as  ice  water,  or,  for  more  permanent 
effect,  ill  ice-bacfs;  other  simple  remedies  are  almn  solution,  viiiei^ar, 
dry  lint;  more  powerful  lisemostatics  are  li(].  ferri  persulphate,  tur- 
pentine, creosote,  hot  iron. 

Ill  tlie  use  of  these  remedies  it  should  be  remembered  that  in  proportion  as  an 
incised  wound  is  disturbed,  and  its  sensitive  surfaces  exposed  to  irritation,  tlie 
possibility  of  prompt  union  is  diminished;  as  a  rule,  therefore,  where  compres- 
sion or  ligation  will  answer,  avoid  styptics,  and  resort  to  them  only  when  it 
makes  no  difference  whether  the  wound  suppurates  or  not. 

Compression  m;sy  be  required  for  immediate  or  permanent  effect. 
For  immediate  compression,  use  the  fingers,  thumb,  or  a  key,  ac- 
cording to  the  situation  and  depth  of  the  artery. 

The  arteries  more  often  requiring  compression,  and  the  points  at  which  pres- 
sure is  to  be  made,  are,  the  carotid  against  the  vertebra;,  with  the  fingers  of 
the  right  hand  applied  along  the  anterior  border  of  the  sterno-mastoid  muscle, 
about  the  middle  of  the  neck;  the  subclavian  against  the  tirst  rib,  with  the  right 
thumb  behind  the  outer  border  of  the  relaxed  sterno-cleido-mastoid  muscle;  the 
brachial  against  the  humerus,  with  the  fingers  placed  along  the  inner  side  of 
the  belly  of  the  biceps  about  the  middle  of  the  arm;  the  femoral  against  the 
pubic  bone  just  below  Poupart's  ligament,  with  the  thumb. 

For  more  permanent  compression  use  the  tourniquet,  where  it  can 
be  applied  without  harm,  as  to  the  femoral. 

The  best  form  of  tourniquet  for  this  purpose  compresses  the  limb  at  but  two 
points  (Fig.  168),  namely,  over  the  artery,  and  at  an  opposite  point;  this  tourni- 
quet can  be  used  for  compression  of  the  femoral  or  abdominal  arter3^ 

Compression  as  a  permanent  hasmostatic,  as  in  venous  haemor- 
rhage, bleeding  from  numerous  small  vessels,  and  especially  when 
parenchymatous,  must  be  made  with  the  nicely 
adjusted  compresses,  and  bandages,  applied 
from  the  toes  or  fingers  above  the  wound. 
Ligation  is  practiced  when  the  bleeding  vessel 
is  an  artery;  in  an  ordinary  wound  the  ligature 
sliould  be  carbolized  catgut,  which  admits  of 
the  immediate  and  complete  closure  of  the 
wound  ;  silk  is  best  if  the  wound  is  to  heal  by 
granulation.  If  the  artery  has  retracted  and 
cannot  be  isolated,  take  up  with  the  forceps, 
or  with  a  curved,  threaded  neeedle,  the  con- 
nective tissue  into  which  the  artery  has  with- 
drawn, and  inclose  the  whole  in  the  ligature. 
Cut  the  ends  of  the  catgut  ligature  close,  but  let  one  end  of  the  silk 
ligature  de[)end  from  the  wound.  Torsion  may  be  practiced  when 
the  arteries  are  small.  Seal  hermetically  with  collodion,  if  there  is 
no  gaping  of  edges.  Employ  common  adhesive  plaster,  or,  better, 
adhesive  rubber  plaster,  if  gaping  is  slight;  add  sutures,  if  it  gape 


INJURIES  or  Till-:  ri:(;i'Mi:NTM{Y  system.   305 

witU'ly,  tie  with  tlie  surgeon's  knot,  l)uf,  do  not  draw  (hcni  so  firndy 
as  to  cause  stranjiulation  of  the  integiunent  (Fig.  245)  j^  ^Pp'}'  S"*-"'' 
aiUIitional  dressing  as  will  secure  perfect  rest;  change  the  dressin" 
only  for  clcaidiness;  remove  sutures  when  they  irritate,  or  no  longer 
sup[)ort  the  wound. 

;j.  Contused  and  lacerated  wounds-  may  he  simple  solutions 
of  continuity,  or  l)e  attended  wilii  loss  of  substance.  The  borders 
are  generally  uneven  tags,  and  not  unfre(|uently  large  ilaps  of  the 
soft  pans  hang  in  the  wound,  having  a  bluish-red  color  ;  the  skin 
for  some  distance  is  often  del  ached  from  the  fascia,  especially  if  the 
contusing  force  was  combined  with  tearing  and  twisting;  tendons  are 
torn  or  pulled  out;  the  skin-wound  usually  gives  no  means  of  judging 
of  the  extent  and  depth  of  the  contusion.  The  pain  is  not  great,  es- 
pecially if  parts  have  been  crushed;  the  bleeding  is  slight,  and  not 
in  a  stream;  even  if  large  arteries  and  veins  are  involved,  the  blood 
will  ooze  from  the  wound. 

This  is  due  to  the  plujrgiiig  of  the  arteries  by  the  in-rolling  of  their  coats,  and 
feeble  action  of  tiie  liean  from  sliock. 

AVhen  reaction  occurs,  hemorrhage  may  take  place  from  vessels 
which  have  not  previously  bled,  and  now  require  the  ligature.  The 
treatment  depends  upon  the  extent  of  injury;  if  slight,  the  parts  may 
be  trimmed  with  the  knife,  and  the  edges  be  converted  into  an  in- 
cised wound.  The  severe  forms  must  lieal  by  secondary  union,  and 
only  after  the  dead  tissues  have  been  separated  by  granulation. 
The  first  applications  to  an  ordinary  contused  and  lacerated  wound 
should  be  cold,  to  diminish  the  tendency  to  excessive  suppuration. 
This  is  best  effected  by  immersion  in  cold  carbolized  water,  kept 
cool  by  ice;  if  immersion  is  impracticable,  the  part  may  be  sur- 
rounded by  ice-I)laddcrs,  or  ice-coniprcsses;  irrigation  with  cold 
water  may  be  employed,  but  is  less  reliable,  tlie  temperature  of 
the  water  varying  from  54°  to  90°  F.,  as  the  patient  may  prefer. 
This  treatment  shoidd  be  continued  eight  to  twelve  days,  when  the 
part  may  be  removed  from  the  water  and  dressed  with  cloths  wet 
with  carbolized  water,  covered  with  oiled  silk.  In  many  cases,  the 
hot  water  treatment  may  well  be  substituted  at  an  early  period, 
or  adopted  from  the  first  to  hasten  the  separating  process. 

The  water  bath  does  not  favor  the  escape  of  pus,  but  rather  prevents  it;  and 
hence  where  tliere  is  suppuration  from  a  cavity  the  water  bath  is  of  no  use,  but 
is  even  injurious:  it  should  be  discontinued  when  deep,  progressive  iuHannnation 
extends  beyond  tlie  wound.  It  must  be  remembered  that  the  water  bath  greatlv 
retards  tiie  healing  process,  and  hence  the  necessity  for  discontinuing  it  as  earlv 
as  practicable,  and  substituting  simple  dressings. 

4.  Gunshot  w^ounds^  vary  in  extent  and  severity  according  to 
1  T.  Bryant.  2  x.  liillrotli.  3  T.  Longmore. 

20 


306  OPERATIVE  SURGERY. 

the  nntiire  of  the  missiles  and  the  conditions  under  which  they  ex- 
pend their  force.  Wlien  a  cannon-ball  at  full  speed  strikes  in  direct 
line  a  part  of  the  body  it  carries  away  all  before  it;  in  case  the  force 
gf  the  cannon-shot  is  partly  expended,  the  extrenuty  or  portion  of 
the  trunk  may  be  equally  carried  away,  but  the  laceration  of  tlie  re- 
maining parts  of  the  body  will  be  greater,  and  the  surface  of  the 
■wound  Avill  be  less  even  ;  if  the  speed  be  diminished  so  that  the  pro- 
jectile becomes  spent,  there  will  not  be  removal  of  the  part  of  the 
body  struck,  but  the  external  ai)i)earance  will  be  limited  usually  to 
ecchymosis  and  tumefaction,  without  division  of  surface,  or  even 
these  may  be  wanting,  notwithstanding  the  existence  of  serious  in- 
ternal disorganization;  should  a  cannon-ball  strike  in  a  slanting  direc- 
tion, the  external  appearance  of  the  wonnd  will  be  similar  to  those 
just  described,  according  to  its  velocity,  modified  only  in  extent  by 
the  degree  of  obliquity  with  which  the  shot  is  carried  into  contact 
with  the  trunk  or  extremity  wounded;  large  fragments  of  heavy 
shells  generally  produce  immense  laceration  and  separation  of  the 
parts  against  which  they  strike,  but  do  not  carry  away  or  grind,  as 
round  shot;  small  projectiles,  with  force  enough  to  penetrate  the 
body,  leave  one  or  more  openings,  the  external  appearances  of  which 
also  vary  according  to  their  form  and  velocity;  when  the  niusket- 
ball  strikes  at  a  distance  from  the  weapon  by  which  it  was  propelled, 
but  still  jireserves  great  velocity,  an  opening  is  observed,  irregularly 
circular,  Avith  edges  generally  a  little  torn,  the  whole  wound  is 
slightly  inverted,  and  there  may  be  darkening  of  the  margin,  of  a 
livid  purple  tinge,  from  the  effects  of  contusion,  or  it  may  be  simply 
dead-like  and  pale ;  should  the  ball  have  passed  out,  the  Avound  of 
exit  will  be  j^robably  larger,  more  torn,  with  slight  eversion  of  its 
edges,  and  protrusion  of  the  subcutaneous  fat,  which  is  thus  ren- 
dered visible ;  these  appearances  are  the  more  easily  recognized 
the  earlier  the  wound  is  examined,  and  are  more  obvious  if  a  round 
musket-ball  has  caused  the  injury  than  when  it  has  been  inflicted 
by  a  cylindro-conoidal  bullet. 

A  nnisket-ball  ordinarily  causes  either  one  wound,  as  when  after  entering  it 
lodges,  or,  as  sometimes  happens,  from  its  escaping  again  bj'  the  wound  of  en- 
trance; or  two  wounds,  from  making  its  exit  at  some  point  remote  from  the 
spot  wiiere  it  entered;  but  occasionally  leads  to  a  greater  number  of  openings; 
this  last  result  maj' happen  from  tlie  ball  splitting  into  two  or  more  portions 
within  the  body,  and  causing  so  many  wounds  of  exit;  the  number  of  wounds 
made  b}'  one  ball  maj'  be  increased  by  its  traversing  two  adjoining  extremities 
of  the  same  person,  or  even  distant  ]iarts  of  tiie  l)ody,  from  accidental  relative 
position  at  the  time  of  the  injury.  The  two  openings  made  by  one  ball  may 
liold  such  a  relative  situation  as  to  lead  to  the  mistake  of  their  being  supposed 
'to  be  caused  b}'  two  distinct  balls.  Length  of  traverse,  and  consequent  distance 
'between  the  two  openings,  parts  of  the  body  brought  into  unusual  relations 
from  peculiarities  of  posture,  and  [leculiar  deflections  of  the  ball,  may  all  be 


IXJURIES   OF  THE   TEGUMENTARY  SYSTEM.    307 

sources  of  this  error.  The  appearances  of  wounds  resultin;j  from  penetrating 
missiles  of  irregular  forms,  as  small  pieces  of  shells,  musket-balls  flattened 
against  stone*,  and  others,  differ  from  those  caused  by  ordinary  bullets  in  being 
accompanied  with  more  laceration,  according  to  their  length  and  form;  being 
usually  projected  with  considerably  less  force  than  direct  missiles,  such  projec"- 
tiles  ordinarily  lead  to  only  one  aperture,  that  of  entrance. 

A  wound  by  musket-shot  is  attended  with  an  amount  of  pain  which 
varies  verv  much  in  degree  according  to  the  kind  of  wound,  and  con- 
dition of  mind,  and  state  of  constitution;  sometimes  it  is  described 
as  a  sudden,  smart  stroke  of  a  cane;  in  other  instances  as  tlie  shock 
of  a  heavy,  intense  blow;  occasionally  the  pain  will  be  referred  to  a 
part  not  involved  in  the  track  of  the  wound ;  when  a  ball  does  not 
penetrate,  but  simi)ly  inflicts  a  contusion,  the  pain  is  described  as 
more  severe  than  where  an  opening  has  been  made  by  it.  Asa  gen- 
eral rule,  the  graver  the  injury,  the  greater  and  more  persistent  is 
the  amount  of  shock. 

In  the  examination  of  these  wounds  it  is  important  to  place  the 
patient,  as  nearly  as  can  be  ascertained,  in  a  position  similar  to  that 
in  which  he  was,  in  relation  to  the  missile,  at  the  time  of  being 
struck. 

When  only  one  opening  has  been  made  by  a  ball,  it  is  to  be  presumed  that  it 
is  lodged  somewhere  in  the  wound,  and  search  must  be  made  for  it  accordingly. 
But  even  where  two  openings  exist,  and  evidence  is  afforded  that  these  are  the 
apertures  of  entrance  and  exit  of  one  projectile,  examination  should  still  be 
made  to  detect  the  presence  of  foreign  bodies.  Portions  of  clothing,  and  other 
harder  substances,  are  not  unfref|uently  carried  into  a  wound  by  a  ball;  and, 
though  it  itself  may  pass  out,  these  may  remain  behind,  either  from  being  di- 
verted from»the  straight  line  of  the  wound,  or  from  being  caught  and  impacted 
in  the  fibrous  tissue  through  which  the  ball  has  passed.  The  inspection  of  the 
garments  worn  over  the  part  wounded  may  often  serve  as  a  guide  in  determin- 
ing whether  foreign  bodies  have  entered  or  not,  and,  if  so,  their  kind. 

Of  all  instruments  for  conductinir  an  examination  of  a  gunshot 
wound,  the  finger  is  the  most  appropriate.  By  its  means  the  direc- 
tion of  the  wound  can  be  ascertained  with  least  disturbance  of  the 
several  structures  through  which  it  takes  its  course.  The  index  fin- 
ger naturally  occurs  as  the  most  convenient  for  this  employment; 
but  the  opening  through  the  skin  is  sometimes  too  contracted  to 
admit  its  entrance,  and  in  this  case  the  substitution  of  the  little  fin- 
ger will  usually  answer  all  the  purposes  intended.  When  the  finger 
fails  to  reach  sufficiently  far,  owing  to  the  depth  of  the  wound,  the 
examination  is  often  facilitated  by  pressing  the  soft  parts  from  an 
opposite  direction  towards  the  finger-end.  Where  the  finger  is  not 
sufficiently  long  to  reach  the  bottom  of  the  wound,  even  when  the 
soft  parts  have  been  approximated  by  pressure  from  an  opposite  di- 
rection, and  when  the  lodgment  of  a  projectile  is  suspected,  a  probe 
is  the  best  substitute.     It  may  be  single,  n  (Fig.  246),  or  jointed, 


308 


OPERATIVE  SURGERY. 


Y\v..  2-tG. 


It  must  be  employed  with  great  nicety  and  care,  for  it  may 
inflict  injury  on  vessels  or  other 
structures  which  ha\e  escaped 
from  direct  contact  with  the 
ball,  but  have  returned,  by  their 
elasticity,  to  the  situations  from 
which  they  had  been  pu.^hed  or 
drawn  aside  during  its  passage. 
But  frequently  it  is  difficult  to 
determine  whether  any  solid 
body  felt  with  the  probe  is  lead, 
and  for  this  purpose  the  end  of 
the  i)robe  may  be  of  porcelain, 
which  is  marked  only  by  lead,^ 
a  (Fig.  247),  or  which  has  a 
burr,  h,  j  (Fig.   24G),  which  will  chip  off  fragments  of  lead  when 

rotated  on  the  ball.  An  electrical 
probe  has  been  devised  "^  which  is 
very  delicate  in  its  action. 

It  consists  of  two  pointed  steel  wives,  pro- 
jecting about  four  inches  from  an  ivory 
handle  (Fig.  248);  thej'  are  surrounded 
,y,,;,^,,^,)  near  their  points  by  a  tube  of  vulcanite 
inclosed  in  a  slotted  tube  of  German  silver, 
and  may  be  moved  slightly  forward  so  as 
g  '''iaaa^.  -  i-rif*'°°T^j '^'^  project  beyond  this  by  means  of  a  but- 

ton to  which  they  are  connec^d,  sliding 
in  the  slot;  the  other  ends  of  the  wire  are 
connected  with  the  terminals  of  a  galvanic  battery,  forming  an  open  circuit;  the 
battery  is  formed  of  a  zinc  and 
carbon  element,  inclosed  in  a  case 
of  hardened  India-rubber  hermet- 
ically sealed,  the  exciting  liquid 
being  bisulphide  of  mercury;  for 
use,  the  probe  is  pushed  into  the 
wound  until  a  resistance  is  encountered  which  in  the  judgment  of  the  operator 
may  be  the  bullet.  The  points  are  then  protruded  and  the  instrument  turned 
about,  if  necessary,  until  both  points  touch  the  object,  when,  if  it  be  the  bullet 
sought,  the  circuit  is  completed  by  metallic  contact,  actuating  the  armature  of 
an  electromagnet  and  causing  it  to  ring  a  bell.  A  small  pocket  instrument 
has  also  been  invented. s 

As  soon  as  the  presence  of  a  ball  or  other  foreign  body  is  ascer- 
tained it  should  be  removed;  if  it  be  lying  within  reach  from  the 
the  wound  of  entrance  it  should  be  extracted  through  this  opening 
by  means  of  some  of  the  various  instruments  devised  for  the  pur- 
pose O;  Fig.  24G,  e,/,  Fig.  247), 

1  E.  Nelatou.  2  m.  Trouv6.  3  x.  Longmore. 


Fig.  248. 


INJURIES   OF   THE   TEGUMENTARY  SYSTEM.    309 


The  way  to  tlie  removal  of  a  bullet  may  often  l)e  smoothed  by  jii(lirioiif.ly 
clearing  away  the  libres,  amoiif^  whieh  it  is  iod^^eil,  during  the  examination  by 
the  tinger;  and  sometimes,  by  means  of  the  finger  in  the  wound,  and  external 
pressure  of  the  surrounding  parts,  the  i)rojeetile  may  be  brought  near  to  the 
aperture  of  entrance,  so  that  its  extraction  is  still  further  facilitated.  Such 
foreign  substances  as  pieces  of  cloth  can  usually  be  brought  out  In'  the  finger 
alone,  or  hy  |)ressing  them  between  the  linger  and  a  silver  probe  inserted  for  the 
purpose.  Sometimes  a  long  pair  of  dressing-forceps,  guided  by  the  finger,  is 
found  necessary  for  effecting  this  object.  Caution  must  be  used  in  employing 
forceps,  where  the  foreign  substance  is  out  of  sight  and  of  such  a  quality  that 
the  soft  tissues  may  be  mistaken  for  it.  It  does  not  often  hajipen  that  it  is  nec- 
essarj'  to  enlarge  the  openings  of  wounds  to  remove  balls,  altlnjugh  a  certain 
amount  of  constriction  of  the  skin  may  be  expected  from  the  addition  of  the 
iuslrument  em|)loyed  in  the  extraction;  but  if  much  resistance  is  offered  to 
their  passage  out,  it  is  better  to  divide  the  edges  of  the  fascia  and  skin  to  the 
amount  of  enlargement  required  than  to  use  force.  In  removing  fragments  of 
shells  or  detached  jiieces  of  bone,  the  fascia  and  skin  have  almost  invariably  to 
be  divided  to  a  considerable  extent. 

In  instances  where  the  foreif^n  body  has  not  completely  penetrated, 
but  is  found  1}  ing  beneath  the  skin  away  from  the  wound  of  en- 
trance, an  incision  must  be  made  for  its  extraction;  before  using  the 
knife,  tlic  sul)staiice  to  be  removed  should  be  fi.xed  in  siUi,  by  pres- 
sure on  the  surroiindin<r  ])arts;  in  the  instance  of  a  round  ball,  the 
incision  should  be  carried  beyond  the  length  of  its  diameter;  an  ad- 
dition of  half  a  diameter  is  usually  sufficient  to  admit  of  the  easy  ex- 
traction of  the  ball.  In  removing  conical  balls,  slugs,  fragments  of 
shells,  stones,  and  other  irregularly-shaped  bodies,  the  surgeon  can- 
not be  too  guarded  in  arranging  so  that  the  fragment  will  present 
its  long  axis  in  line  with  the  track 
of  the  wound.  To  effect  this  object, 
it  is  necessaiy  to  seize  the  missile  in 
such  manner  as  to  bring  its  long  axis 
to  correspond  with  that  of  the  track 
of  the  wound.     (Fig.  249.) 


Fig.  249. 


When  there  is  reason  for  concluding  that  a  ball  or  other  foreign  body  has 
lodged,  but  after  manual  examination,  and  observation  as  well  by  varied  posture 
of  the  part  of  the  body  supposed  to  be  implicated  as  by  indications  derived  from 
the  patient's  sensations,  effects  of  ])ressure,  or  injury  to  nerves,  and  all  other 
circumstances  which  may  lead  to  information,  the  site  of  lodgment  cannot  be 
ascertained,  the  search  should  not  be  persevered  in  to  the  distress  of  the  patient. 
Neither,  although  the  site  of  lodgment  be  ascertained,  if  extensive  incisions  are 
required,  or  if  there  is  danger  of  wounding  important  organs,  should  the  at- 
tempts at  extraction  be  continued.  Either  during  the  process  of  suppuration, 
by  some  accidental  muscular  contraction,  or  by  gradual  approach  towards  the 
surface,  its  escape  may  be  eventually  efTected;  or,  if  of  a  favorable  form,  and 
if  not  in  contact  witli  nerve,  bone,  or  other  important  organ,  it  may  become 
encysted,  and  remain  without  causing  pain  or  mischief. 


310  OPERATIVE  SURGERY. 

All  foreign  matters  being  removed,  the  wound  must  be  syringed 
with  carbolic  solution  to  its  deepest  recesses,  suitable  drainage  pro- 
vided, and  a  position  of  perfect  rest  secured.  It  may  be  closed  with 
adhesive  strip,  and  ice-bladders  applied,  but  carbolized  spray  and 
solutions  should  be  used  at  each  change  of  the  dressings,  if  possible. 
When  much  local  inflammation  has  set  in,  and  when  there  is  much 
constitutional  fever,  even  without  unusual  local  irritation,  the  non- 
evaporating  or  warm  applications  will  be  found  to  be  the  most  ad- 
vantageous. When  suppurative  action  has  been  fully  established, 
care  must  be  taken  to  prevent  the  accumulation  of  pus,  lest  it  bur- 
row, and  sinuses  become  established,  not  an  unfrequent  result  of 
want  of  sufficient  caution  in  this  regard;  if  much  tumefaction  of  mus- 
cular tissues  beneath  fascias  occurs,  or  abscesses  form  in  them,  free 
incisions  should  be  at  once  made  for  their  relief. 

5.  Poisoned  wounds  are  wounds  inoculated  with  a  poison  ca- 
pable of  jn-oducing  either  (1)  fever  and  its  complications;  or  (2) 
symptoms  of  specific  general  poisoning;  or  (3)  definite  diseases. ^ 
(1.)  The  first  variety  of  poison  is  developed  in  decomposition  of 
animal  matters,  and  appears  in  butchers,  cooks,  and  those  engaged 
in  dissections. 

Ordinary  di5;section  wounds  are  generally  harmless,  unless  the  person  is  very 
susceptible;  it  is  in  the  bodies  of  those  dead  of  pyseniial  diseases,  as  puerperal 
peritonitis,  that  the  poison  is  especially  virulent;  in  these  cases  it  may  enter  the 
system  even  through  the  unbroken  skin.^ 

The  effects  of  the  poison  may  appear  in  various  degrees  of  sever- 
ity; (a)  there  may  be  a  slight  induration  of  the  part,  with  moderate 
pain,  followed  by  a  dry  scale  which  recurs  as  often  as  it  is  removed; 
the  epidermis  thickens  over  it  and  forms  a  painful,  wart-like  nodule 
—  the  anatomical  tubercle  ;  ^  (6)  there  may  be  an  inflammation  of 
the  lymphatic  vessels  and  axillary  glands  terminating  in  abscesses; 
(c)  the  poison  may  develop  an  acute  septicaemia  and  rapidly  prove 
fatal;*  (jl)  the  course  of  the  poison  may  be  chronic,  involving  the 
glands,  and  inducing  wide-spreading,  phlegmonous  infiaMimations 
and  abscess.^  The  treatment  at  the  outset  should  be  irrigations  of 
the  wound  with  cold  water,  or  sucking  it  with  the  mouth;  immediate 
cauterization  is  unadvisable;^  if  lymphangitis  appear,  place  the  limb 
in  quiet  position  and  apply  a  lotion  of  opium  and  lead ;  if  abscesses 
form,  evacuate  them  early,  disinfect  the  interior  with  carbolic  solu- 
tions, give  opium  to  alleviate  pain,  and  wine  and  nourishing  food  for 
the  general  strength;  if  the  disease  run  an  acute  course,  this  treatment 
must  be  much  more  energetically  enforced.  (2.)  The  second  variety 
of  poison  emanates  from  venomous  animals,  as  wasps,  hornets,  bees, 

1  T.  Holmes.  2  Si,.  J.  Paget.  3  g.  Wilkes.  *  t.  Billroth. 

6  Sir  J.  Paget;  T.  Billroth. 


INJURIES   OF   THE   TEGUMENTARY  SYSTEM.    311 

snakes,  scorpions.  The  effects  of  the  sting  of  wasps  and  bees  rarely 
extend  bevond  the  immediate  vicinity  of  the  injury,  and  require,  at 
the  most,  only  the  application  of  vinegar,  or  amnioiiia  in  solution, 
and  sin)j)le  domestic  remedies,  as  bread-and-water  j)oultice.  The 
same  treatment  may  be  pursued  in  the  bites  of  snakes,  unless  they 
are  known  to  be  dangerously  poisonous,  as  fliat  of  the  rattlesnake; 
in  such  a  case  promj)!  action  is  required,  namely,  a  ligature  should 
be  tied  so  firmly  around  the  part  as  to  interrupt  all  circulation;  if  it 
is  a  finger,  amputate  at  once;  otherwise  excise  the  wound  thoroughly, 
and  suck  the  blood  from  the  part;  finally,  cauterize  the  surface.  The 
subsequent  treatment  will  depend  upon  the  sjnqitoms  as  they  de- 
velop. (3.)  The  third  ^  form  of  poison  causes  specific  diseases,  and  is 
derived  from  the  secretions  of  animals  affected  with  glanders  and 
hydrophobia.  Glanders  in  man  results  from  inoculation  of  a  wound 
with  the  pus  from  the  nares  of  the  affected  horse;  it  excites  severe 
and  widespread  inrtamination,  witli  all  the  symptoms  of  acute  septi- 
eajmia.  The  treatment  must  be  directed  by  the  symptoms.  Hydro- 
phobia results  from  the  inoculation  of  a  wound  by  the  saliva  of  a 
rabid  animal,  as  a  dog  or  cat ;  the  bite  usually  heals  readily,  but  it 
is  more  favorable  if  the  wound  suppurates  freely;  the  disease  rarely 
appears  under  six  weeks,  and  fre(juently  later.  The  treatment 
should  be  cauterization  of  the  wound,  and  promotion  of  suppuration; 
after  the  ajipearance  of  symptoms  there  is  no  hope.  Excision  of  the 
cicatrix  mav  he  resorted  to,  though  amputation  even  has  proved  use- 
less. 

G.  Frost-bite,^  or  chilling  of  parts  by  cold,  occurs  more  often 
when  cold  is  accompanied  with  moisture;  closely-fitting  clotlies, 
which  impede  circulation,  increase  the  predisposition.  It  may  be  so 
slight  as  to  cause  simple  numbness  of  the  fingers  or  toes,  and  white- 
ness of  the  skin;  when  these  symptoms  subside  the  skin  becomes 
red,  the  fingers  swell,  and  there  is  a  pccidiar  itching  and  prickling; 
no  other  treatment  is  required  than  rubbing  the  parts  and  restoring 
the  circulation  by  degrees;  the  redness  may  remain  long  after  re- 
covery, and  even  become  permanent.  A  severe  form  appears  in  the 
rising  of  vesicles  with  complete  loss  of  sensation;  there  is  now 
danger  of  nwrtification  ;  the  treatment  consists  in  a  very  gradual 
change  to  a  higher  temperature,  snow  or  ice  may  be  rubbed  upon 
the  parts,  or  cloths  dipped  in  ice-water  applied.  Or,  there  may  be 
the  formation  of  eschars  ;  the  parts  are  then  quite  destroyed  by  the 
cold,  and  slouglis  form  as  in  severe  burns;  the  treatment  is  the 
same  as  in  the  milder  cases,  but  the  ulcers  which  result  from  the 
slough  re([uire  a  long  period  in  which  to  cicatrize. 

7.  Chilblains,   pernioes,  result  from  repeated  freezings,  causing 

1  T.  Billroth. 


312  OPERATIVE  SURGERY. 

paralysis  of  the  capillaries  with  serous  exudations  in  the  cutis.^ 
There  may  be  simple  congestion  attended  with  itchin;^,  alternating 
with  extreme  tenderness;  or  there  may  be  vesication,  and,  in  extreme 
cases,  death  of  the  skin  or  areolar  tissue;  usually  there  is  a  daily  at- 
tack of  congestion  occurring  in  the  afternoon  or  evening,  with  in- 
creased heat  and  swelling,  followed  by  itching,  then  swellings  and 
finally,  soreness,  aching,  and  extreme  sensibility.^  In  treatment, 
direct  loosely  fitting  and  warm  coverings  for  the  parts,  and  applica- 
tions which  relieve  the  local  distress;  the  latter  must  be  selected  by 
the  experience  of  each  patient.  Those  generally  usefid,  where  the 
skin  is  unbroken,  are  stimulating  liniments,  as,  camphorated  oil; 
equal  parts  turpentine  and  copaiba;  tr.  iodine;  tr.  cantharides  1  part, 
and  soap  liniment,  3  parts;  solutions  of  nitrate  of  silver;  to  relieve 
itching,  cold  water,  or  hot  mustard  water  are  most  effective;  if  there 
are  vesicles,  collodion  is  very  serviceable  ;  for  ulcers,  bals.  Peru  is 
necessary. 

8.  Burns  and  scalds  may  be  of  different  degrees  of  severity,  but 
the  risk  to  life  is  to  be  measured  by  the  extent  of  surface  involved; 
they  are  most  serious  to  the  young  and  the  old,  but  at  all  ages  ex- 
tensive burns  are  to  be  feared  ;  first,  from  their  immediate  depressing 
effects;  second,  from  inflammatory  complications;  and,  third,  from 
suppuration  ;  when  the  injury  is  over  the  thoracic  region,  chest  com- 
plications are  liable  to  follow  ;  if  over  the  abdomen,  dangerous  in- 
testinal affections  may  ap[)ear.^  Tlie  several  grades  of  burns  are  as 
follows:  (1.)  They  may  be  so  slight  as  to  cause  simple  redness  of  the 
skin,  due  to  a  dilatation  of  the  capillaries,  and  slight  exudation  of 
serum  in  the  tissue  of  the  cutis  ;  there  is  a  mild  grade  of  inflamma- 
tion, followed  in  many  cases  with  detachment  of  the  epidermis;  the 
pain  is  severe  for  a  few  hours.  The  treatment  depends  upon  the  ex- 
tent of  surface  involved.  If  it  is  limited,  apply  soothing  remedies, 
as,  cold  water,  lead  water,  scraped  potatoes,  or  such  one  of  the  do- 
mestic articles  recommended  as  may  be  convenient.'*  (2.)  The  imrn 
may  be  deeper,  followed  by  the  formation  of  vesicles,  due  to  the 
rapid  escape  of  fluid  from  the  capillaries  between  the  mucous  and 
horny  layer.^  If  this  burn  is  quite  limited,  recovery  is  rapid  and 
satisfactory;  but  if  spread  over  a  large  surface,  the  shock  and  col- 
lapse may  be  severe,  and  recovery  uncertain.  The  treatment  should 
be  directed  first  to  the  shock  and  depression,  which  may  be  mitigated 
by  external  warmth  with  hot  drinks,  stimulants,  and  opium  to  relieve 
pain;  next,  remove  the  clothes,  with  care  to  avoid  tearing  off  the  ves- 
icles, and  puncture  the  blisters  at  the  most  depending  part  to  allow 
the  escape  of  the  fluid  without  the  removal  of  the  pellicle,  which  is  the 
best  protection  of  the  injured  surface.     The  local  ajjplications  should 

1  T.  BiUroth.  2  x.  Smith.  3  x.  Bryant.  *  S.  D.  Gross. 


DISEASES  OF  THE   TEGUMENTARY  SYSTEM.    313 

soothe  tlie  irritated  parts  and  protect  them  from  the  air:  for  tliis 
purpose  the  tollowiiiLr  remedies  may  be  used,  aeconlinj^  as  they  are  at 
hand:  equal  parts  of  linseed  oil  and  lime-water  on  lint,  and  covered 
with  cotton-wool;  carbolized  oil;  a  complete  covering  with  flour; 
white  lead  in  the  form  of  |)aint;  ^  zinc  ointment  on  lint.  (3.)  In  this 
form  the  destruction  is  deej)er  and  the  eschars,  or  sloughs,  result 
with  varying  degrees  of  sup[)uration.  If  the  surface  involved  is 
considerable,  reaction  will  probably  not  occur,  and  death  will  soon 
follow.  If  limited  in  extent,  the  early  treatment  must  be  directed  to 
relief  from  the  shock,  and  then  to  the  immediate  dressing  of  the 
surface.  The  second  dressings  must  i>e  applied  with  reference  to 
the  separation  of  sloughs,  and  the  most  important  is  the  carbolic 
acid  dressing,  as  follows:  carbolic  acid,  one  ounce  to  a  pint  of  olive 
or  linseed  oil,  or  an  ointment  made  of  carbolic  acid  3iv.,  lard  %\y., 
and  ca<tor  oil  5'-i  ^  *o  the  other  surfaces  involved,  api)ly  the  oil  and 
lime-water,  or  zinc,  or  creosote  ointment  gtts.  x.  to  lard  an  ounce; 
or  a  lotion  of  tr.  iodine  3i-  to  water  one  pint.  When  the  sloughs 
separate,  ulcers  are  left,  which  heal  very  slowly  by  granulation. 
The  slow  process  of  healing  is  attended  with  contractions  of  the 
cicatricial  tissues,  which  tend  powerfully  to  cause  distortions  and 
result  in  disfigurement  and  impairment  of  the  functions  of  the  parts 
involved.  The  most  efhcient  preventive  measure  is  elastic  exten- 
.«ion  by  rubber  straps,  so  applied  as  to  maintain  gentle,  but  firm,  re- 
sistance to  the  contraction,  without  pain  or  inconvenience. 


CHAPTER  XXVIII. 

DISEASES   OF  THE   TEGUMENTARY  SYSTEM  AND 
SPECIAL  OPERATIONS. 

I.    THE  SKIN. 

The  epidermis  and  papillary  body  form  the  more  superficial  por- 
tion of  the  integument,  the  former  being  an  insensible  covering  of 
flattened  cells,  while  the  latter  is  richly  supplied  with  vessels  and 
nerves,  and  reacts  to  stimulants  by  hypera?mia  and  inflammation; 
the  two  constitute  a  vegetative  whole,  the  latter  being  the  matrix  of 
the  former,  through  the  constant  supply  of  young  cells;  a  morbid 
sub-activity  of  this  process  results  in  various  hypertrophies  of  these 
tissues. 3 

1.  The  callosity  is  a  circumscribed  thickening  of  the  horny  layer 
of  the  epidcniiis,  and  consists  of  many  strata  of  epidermic  scales 
superimposed  on  one  another,  the  deeper  resting  on   the  rete  nmco- 

1  S.  D.  Gross.  2  J.  Lister.  8  E.  Rindtleisch;  F.  Hebra. 


314 


OPERATIVE  SURGERY. 


Fig.  250. 


sum;  it  increases  gradually  by  the  continual  addition  of  new  epider- 
mic tissue  from  below,  and  finally  develops  into  a  plate  which  stead- 
ily becomes  more  elevated;  its  consistence  depends  upon  its  moisture, 
and  varies  from  the  elastic  and  flexible  to  the  horny  and  brittle;  it 
appears  on  parts  of  the  skin  exposed  to  a  frequently  recuiring  but 
not  continuous  pressure,  and  which  rests  on  bone,  as  the  heads  of 
the  metacarpal  and  tarsal  bones;  they  sometimes  form  as  large  and 
painful  plates  on  the  sole  or  palm.^  The  treatment  consists  in  re- 
moval of  the  growth  and  prevention  of  its  recurrence;  after  pro- 
longed soaking  in  hot  water,  apply  glacial  acetic  acid,  or  nitrate  of 
silver,  and  detach  the  plates  which  form;^  protect  the  part  from 
pressure  of  the  substance  which  caused  the  original  thickening. 

2.  The  corn  (Fig.  250)  is  a  callosity  so  modified  by  the  yielding 
of  the  deeper  parts  to  the  external  pres- 
sure that  the  deep  layers  assume  the  form 
of  a  nail  (Clavus)  with  its  point  pene- 
trating the  cutis  (Fig.  250);  the  external 
elevation  is  small,  but  the  sweliinq;  from 
the  under  surface  of  the  thickened  horny 
layer  forms  a  truncated  cone  with  the 
axis  at  right  angles  to  the  surface  of  the 
skin  into  which  it  has  penetrated  for  some 

distance  ;  like  the  callosity,  it  varies  in  consistence  with  the  degree 
of  moisture,  on  exposed  surfaces  being  hard,  but  between  the  toes 
soft;  a  bursa  may  form  when  the  corn  penetrates  the  skin.^  The 
treatment  is  the  saiue  as  for  a  callosity. 

3.  Warts,  Verruca,  are  overgrowth  of  the  epidermis,  in  which 
the  papillary  body  shares  moi-e  or  less;  the  common  hard  wart 
consists  of  a  circular  group  of  elongated  papillae,  with  their  free 
extremities  slightly  enlarged  and  bulbous,  their  vessels  dilated  and 
extending  close  up  to  the  epidermic  covering. ^  The  treatment 
should  be,  (1)  an  effort  to  turn  the  wart  out  by  pressure  with  the 
finger-nail,  which  frequently  succeeds  with  dry  warts  on  the  face, 
and  moist  warts  on  the  genitnls  ;  ^  (2)  excision  Avith  knife  or  curved 
scissors,  and  cauterization  of  the  base  with  chloride  of  zinc  ;  (3)  de- 
struction by  caustics,  as  chloride  of  zinc,  nitric  acid  ;  (4)  dessica- 
tion  by  applications  of  tr.  iodine  or  acetic  acid. 

4.  The  cutaneous  horn  results  from  hypertrophy  of  a  group 
of  ])apillffi;  in  its  growth  it  may  involve  hair  sacs  and  contain  seba- 
ceous cysts. 3     The  treatment  is  extirpation. 

5.  Erysipelatous  inflammation  is  located  chiefly  in  the  papil- 
lary layer  and  in  the  rete  Malpighii  ;  any  part  may  be  attacked,  but 
it  is  most  fretpient  in  the  head  and  face;   the  local  symptoms   are 

1  F.  Hebra.  2  Qrmsby.  3  £.  Rindfleisch. 


DISEASES  OF  THE   TEGUMENTARY  SYSTEM.    315 


great  rt-dness  and  (Edematous  swelling  of  the  skin,  pain  on  bein^ 
touched,  and  high  fever;  it  lasts  from  one  day  to  three  or  four 
weeks.  The  treatment,  is  laxatives  to  improve  thu  ili^estive  organs; 
then  give  tonics,  as  (jninine  and  iron;  good  diet;  locally,  light  .-cari- 
fieations  are  often  useful,  followed  by  lead  and  opium  lotions;  if  pus 
form  it  must  l)c  evacuated. 

G.  The  furuncle,  boil,^  seems  to  have  its  origin  in  the  death 
of  a  small  portion  of  skin,  or  perhaps  of  a  cutaneous  gland,  which 
becomes  the  centre  of  an  inllammation;  by  infiltration  with  plastic 
matter  the  tissue  of  the  cutis  partly  turns  to  pus  and  partly  becomes 
gangrenous;  the  peculiarity  of  this  form  of  inflammation  is,  that  it 
shows  no  tendency  to  spread,  but  remains  circumscribed,  and  ter- 
minates in  the  detachment  of  the  central  dead  tissue;  regions  where 
the  secretions  of  the  cutaneous  glands  are  particularly  strong  are 
predisposed  to  furuncles,  as  the  axilla,  perineum;  they  occur  more 
often  in  the  emaciated  and  feeble,  but  may  appear  in  the  robust  and 
well-fed. 

There  are  also  constitutional  conditions  and  diseases  which  dispose  to  the 
forniiition  of  boils,  creating  a  diathesis,  furunciilosis,  which  may  prove  very 
exhausting,  especially  to  children  and  old  persons. 

The  disease  appears  first  as  a  red  and  rather  sensitive  nodule  in 
the  skin,  size  of  a  pea  or  bean;  soon  a  small  white  point  forms  on  its 
apex;  the  swelling  spreads  around  this  centre,  and  usually  attains 
the  size  of  a  dollar;  towards  the  fifth  day  the  central  white  point 
becomes  loosened,  and  is  evacuated  as  a  plug  with  pus  mixed  with 
blood  and  shreds  of  tissue;  suppuration  ceases  in  three  or  four  days, 
and  the  cavity  cicatrizes.  The  abortive  treatment  with  ice  is  not 
advisable;  warm,  moist  appli- 
cations should  be  made,  as 
poultices,  to  hasten  suppura- 
tion, and  an  early  opening  be 
made  to  relieve  tension  and 
evacuate  the  contents.  Select 
a  lancet  having  a  fine  point 
and  a  broad,  sharply-cutting 
shoulder;  plunge  the  point 
nearly  vertically  to  the  sur- 
face (Fig.  2.51)  so  deeply  as 
to  reach  the  pus,  and  then  cut  outwards.  To  the  debilitated,  give 
quinine,  iron,  wine,  nutritious  foods. 

7.   Carbunculous  inflammation,  authrax,i  anatomically  resem- 
bles several   furuncles  lyiu.:  close  together,  but  the  process  is  more 
intense  and  inclined  to  spread;  their  chief  seat  is  the  hard  skin  of 
1  T.  Billroth. 


Fig.  251. 


316  OPERATIVE  SURGERY. 

the  back,  especially  in  old  people;  they  first  appear  like  the  furuncle; 
but  s^oon  a  number  of  white  points  form  near  each  other,  the  swelling, 
redness,  and  pain  increases,  and  the  carbuncle  may  attain  the  size  of 
a  soup-dish,  while  plugs  and  gangrenous  shreds  are  detached,  until 
the  skin  appears  perforated  like  a  sieve;  the  process  is  almost  always 
limited  to  the  skin  and  subcutaneous  cellular  tissue,  fasciae,  muscles 
and  arteries  rarely  being  destroyed;  after  the  separation  of  the  cel- 
lular tissue  and  arrest  of  the  process,  luxuriant  granulations  appear 
and  healing  progresses  favorably.  Carbuncle  of  the  back  is  tedious 
and  painful,  but  rarely  causes  death.  The  disease  may,  however, 
attack  other  parts,  as  the  lips,  or  cheeks,  or  head,  and  prove  rap- 
idly fatal;  in  many  cases  of  malignant  carbuncle  the  inflammation 
extends  to  the  cranial  cavity;  but  in  other,  and  the  more  quickly 
fatal,  cases,  the  brain  is  not  affected,  and  the  probability  is  that  there 
is  a  rapidly-occurring  decomposition  of  the  blood  of  which  the  car- 
buncle may  be  the  cause  or  the  result. 

This  decomposition  niaj'  have  its  origin  in  infection  conveyed  by  an  insect 
which  has  previously  been  on  carrion ;  the  high  fever  and  fatal  blood  infection 
are  mostly  results  of  the  local  disease. 

The  ordinary  carbuuL-le  of  the  back  is  easily  recognizL'd  by  its 
broad  inflamed  base  with  perforations  of  the  skin;  on  the  lip,  face, 
or  head,  it  may  be  mistaken  for  erysipelas,  but  is  readily  distinguished 
by  its  hardness,  purplish  color,  severe  pain,  high  fever.  The  treat- 
ment of  all  forms  of  carbuncle  must  be  very  energetic  to  prevent  the 
spread  of  the  disease;  numerous  incisions  should  be  made  early  to 
permit  the  escape  of  the  decomposed  putrid  tissues  and  fluids;  they 
should  be  crucial  in  form,  through  the  whole  thickness  of  the  cutis, 
and  extending  to  the  healthy  skin;  the  applications  to  the  exposed 
surfaces  should  be  strongly  disinfectant,  as  strong  carbolic  acid  solu- 
tions, creosote,  chlorine  water,  or  turpentine;  hot  poultices  may  be 
added  to  hasten  suppuration  unless  they  aggravate  the  pain  or  the 
head  symptoms.  The  general  treatment  should  be  actively  support- 
ing ;  wine  or  whiskey  as  stimulants  ;  quinine  and  iron  ;  opium  both 
to  relieve  pain  and  promote  capillary  circulation, ^  and  easily  digested 
nutritious  food. 

8.  Phlegmonous  inflammation,  celliilitis,^  may  occur  in  any 
part  of  the  body,  but  is  most  frequent  in  the  hand,  forearm,  knee, 
foot,  and  leg;  the  cause  is  often  obscure,  but  it  may  arise  from  inju- 
ries, infection,  cold;  the  spontaneous  form  is  more  frequent  in  the 
extremities,  above  than  below  the  fasciae,  and  is  especially  prone  to 
affect  the  fingers  and  hand,  about  the  nails,  panaritium.  The  disease 
is  a  serous  exudation  from  the  vessels,  and  infiltration  of  the  con- 
nective tissues  with  quantities  of  young,  round  cells;  it  begins  with 
i  F.  C.  Skey.  2  x.  Billroth. 


DISEASES  OF  THE   TEGUMENTARY  SYSTEM.    317 

pain,  swelling,  and  redness  of  the  skin,  and  iisnallv  wiili  liigli  fever; 
the  tissues  beeonie  tense,  there  is  stagnation  in  the  vessels  at  various 
points,  espeeialiy  in  the  capillaries  and  veins,  and  in  some  parts  the 
circulation  ee;ises  entirely,  resulting  in  extensive  gangrene  of  tissues; 
as  the  indaniniation  spreads  the  entire  inflamed  part  is  changed  to 
fluid  matters,  consisting  of  cells,  with  some  serous  fluid  mixed  with 
shreds  of  dead  tissue;  the  process,  finally,  involves  the  skin,  perfo- 
rates it  at  some  point,  and  the  pus  and  debris  escape  externally. 
The  inflammation  n(j\v  ceases  to  extend,  the  walls  of  the  cavity  unite, 
and  the  plastic  infiltration  of  the  part  is  finally  absorbed,  and  the 
tissues  return  to  their  normal  state.  Or,  the  case  may  terminate  fa- 
tally, owing  to  the  absorption  of  the  putrid  products  of  suppuration, 
as  in  deep  collections  about  the  neck  of  old  people.  The  treatment 
aims  to  arrest  the  development  of  the  disease  by  securing  the  earliest 
possible  absorption  of  the  serous  and  plastic  infiltration;  fortius  pur- 
pose light  scarifications  may  be  made,  or  ice  may  first  be  used,  or 
mercurial  ointment  well  rubbed  in,  followed  by  enveloping  the  part 
with  warm,  moist  cloths  or  large  poultices;  if  these  fail,  suppuration 
must  be  hastened  by  hot  poultices;  the  pus  should  be  evacuated  as 
soon  as  detected,  and  from  several  i)unctures  if  it  is  dilYuscd. 

If  the  pus  lie  deeply  in  vascular  parts,  as  the  neck,  the  openinf^  should  be  made, 
not  bv  phmtting  a  bistoury  into  the  swelling,  but  by  careful  dissection,  or  after 
the  skin  and  fascia  are  incised,  by  working  a  blunt  instrument,  as  a  director, 
cautiously  through  the  structures,  and  when  pus  appears,  introduce  the  blades 
of  forceps  and  expand  them.' 

9.  An  ulcer  •  is  a  wounded  surface  which  shows  no  tendency  to 
heal;  it  mostly  starts  from  chronic  inflammation,  and  is  always  pre- 
ceded by  cellular  infiltration  of  tissue;  two  opposite  processes  are 
combined,  namely,  new  formation  and  destruction,  the  latter  result- 
ing from  li(juefaction  of  tissues  through  suppuration  or  molecular  dis- 
integration or  both  ;  two  classes  of  ulcers  result  from  this  antagon- 
ism: (1)  those  in  which  the  new  formation  predominates,  proliferating 
ulcers,  and  (2)  those  in  which  suppuration  and  disintegration  are  most 
prominent,  atonic  or  torpid  ulcers.  For  the  pur|)Oses  of  description 
the  following  forms  are  recognized:  (1)  The  erethitic  or  irritable  ul- 
cer, which  constantly  has  red  and  sensitive  borders,  bleeds  readily, 
and  the  granulations  are  painful  to  the  touch;  the  proper  treatment 
is  the  destruction  of  this  surface  with  nitrate  of  silver  or  the  hot  iron, 
and  the  subsetpient  com])ression  with  adhesive  plaster;  the  hot  iron  is 
but  slightly  painful;  if  this  treatment  is  not  practicable,  zinc  ointment 
or  lead  lotions  may  be  used,  or  other  mild  salves;  (2)  fungous  ulcers 
exist  when  the  granulations  project  above  the  level  of  the  skin  an<l 
are  proliferating;  the  treatment  requires  that  tVic  surface  of  the 
1  J.  Hilton.  -  T.  Billroth. 


318  OPERATIVE  SURGERY. 

granulations  shall  be  destroyed  by  caustics,  as  the  solid  nitrate  of 
silver  or  the  hot  iron;  milder  remedies  are,  compression  with  adhesive 
strips,  and  astringents,  as  oak  bark,  alnm,  Peruvian  bark;  (3)  callous 
ulcers  have  thickened  and  hardened  margins,  owing  to  the  long  dura- 
tion of  chi'onic  inflammation;  the  ulcer  is  torpid,  lies  deeply  below 
the  surface,  with  sharply  rounded  edges,  and  the  surface  is  glazed. 
In  treating  the  more  tractable  cases  the  indications  to  be  met  are, 
to  soften  the  hardened  borders  and  base,  and  to  induce  a  proper 
amount  of  vascularity  in  these  parts  ;  the  former  is  most  thoroughly 
effected  by  the  hot  iron,  or  by  strapping  with  adhesive  plaster  cut 
into  long  strips  and  applied  partially  ai'ound  the  limb  and  very  firmly 
over  the  ulcers,  drawing  its  edges  down  and  towards  each  other;  the 
second  is  best  accomplished  by  moist  warmth,  as  poultices  or  the  con- 
tinued warm  bath. 

It  is  not  always  possible  to  obtain  healing  of  a  callous  ulcer  of  the  leg,  espe- 
cially when  it  is  situated  on  the  anterior  face  and  extends  to  the  periosteum  of 
the  tibia,  or  when  it  stu-rounds  the  leg  like  a  ring. 

10.  Lupus  1  commences  with  small  nodules  in  the  superficial  lay- 
ers of  the  skin,  more  often  on  the  face,  especially  on  the  nose, 
cheeks,  and  lii)s.  They  may  enlarge  and  run  together  so  as  to  form 
large  nodules  and  tuberculous  thickenings  of  the  skin,  L.  hypertro- 
phicus;  or  there  may  be  a  free  exfoliation  of  epidermis  on  their  sur- 
face, L.  exfoliatus  ;  or  the  surface  may  ulcerate,  L.  exulcerans;  with 
strongly  proliferating  granulations,  L.  fungosus;  or  with  raj)id  de- 
struction of  tissues,  L.  exedens. 

The  process  commences  essentially  in  the  connective  elements  of  the  cutis, 
with  ver^' abundant  new  formation  of  vessels;  the  cutis  at  first  becomes  con- 
verted into  separate,  entirely  circumscribed  nests  ;  then  more  diffusely  info  a 
layer  of  small  cells  which  does  not  differ  essentially  from  a  common  granular 
tissue;  the  cells  have  the  form  and  size  of  the  white  elements  of  the  blood,  and 
often  form  under  the  mucous  layer  as  sharply  defined,  large,  round,  or  oval 
masses. 

The  disease  must  be  classified  with  new  growths,  consisting  of 
granular  tissue,  characterized  by  such  a  copious  aggregation  of  small 
exuberant  cells  that  the  elements  of  the  cutis,  and  not  infrequently 
of  the  still  deeper-seated  layers  of  cellular  tissue,  are  completely  dis- 
placed and  destroyed  by  them ;  this  infiltration  soon  results  in  com- 
plete substitution,  and  if  the  exuberant  cells  disappear,  there  is  per- 
manent loss  of  substance  which  may  appear  as  a  special  defect,  or  a 
contraction  of  parts,  or  sometimes  as  a  scar;  the  disfigurements  of 
lupus  may,  therefore,  occur  without  as  well  as  with  open  ulcers,  for 
as  the  infiltrated  parts  recover  they  shrink  to  less  than  their  former 
volume,  as  does  ordinary  cicatricial  tissue,  the  skin  appearing  to  be 
1  R.  Volkman. 


DISEASES  OF   THE   TEGUMENTARY  SYSTEM.    319 

interwoven,  with  irregular,  cicatricial  lines,  wliirli  may  even  acfiiiire 
an  irregularly  filled  surface. 

The  treatment  is  exclusively  local,  and  aims  to  remove  every 
nodule:  (1)  by  destroying  affected  tissues,  and  (2)  by  effecting  in 
parts  still  firm  and  comparatively  healthy  the  absorption  of  lh<!  lu- 
poid cellular  infiltration.  The  most  effective  method  is  as  follows: 
for  the  removal  of  parts  entirely  converted  into  lupoid  tissue,  use 
sharj)  scoops;  give  an  ansusthetic,  and  with  the  scoop  scrape  off  or 
out  all  soft  structures  until  the  part  is  entirely  free  from  the  diseased 
structures;  the  necessary  force  may  i)e  emj)loyed  for  the  scoop  will 
only  remove  diseased  tissues;  touch  the  surface  lightly  with  the  solid 
nitrate  of  silver,  and  cover  it  with  small  pieces  of  lint  which  should 
be  allowed  to  dry,  or  cold  applications  may  be  made.  For  the  re- 
moval of  diffuse  lupoid  infiltrations  with  preservation  of  the  layers 
of  the  skin  resort  to  multiple  puuctiform  scarification,  as  follows:  the 
patient  being  under  an  anajsthetic;,  with  a  narrovv-bladed,  sharp- 
pointed  knife,  make  hundreds  or  even  thousands  of  punctures  two  or 
more  lines  in  depth,  close  to  each  other;  in  many  cases  the  skin  after 
the  completion  of  the  puncturing  appears  of  a  lead  coloi-,  or  even 
suspiciously  white,  and  resembles  chapped  flesh;  but  gangrene  never 
has  ensued;  cover  the  part  with  lint,  jn-ess  it  on  firmly  to  stop  bleeil- 
ing,  and  leave  it  until  it  falls  spontaneously;  repeat  the  operation 
three,  five,  or  even  eight  times  if  necessary,  at  intervals  of  two  to  four 
■weeks;  the  skin  gradually  becomes  firmer  and  loses  its  abnormal 
swelling  and  re<lness,  while  no  cicatrices  are  formed.  If  this  treat- 
ment is  rejected,  caustics  must  be  used;  of  these,  the  caustic  potash, 
or  nitrate  of  silver  in  the  stick,  may  be  selected. 

The  attached  crusts  must  first  be  removed  by  applying  cod-liver 
oil  one  or  two  days;  then  bore  the  caustic  stick  into  the  soft  lupoid 
granulations,  retaining  the  potash  in  contact  with  the  tissue  much 
less  time  than  the  silver;  wipe  off  the  syrupy,  tar-like  mass  with 
pads  of  wadding  until  a  sound,  firm  surface  appears;  now  cease  to 
apply  the  caustics,  for  if  the  application  is  continued  the  erosions  will 
be  too  deep,  and  disfiguring  scars  will  result;  apply  simple  dress- 
ings. 

11.  Elephantiasis  arabum  is  an  hypertrophy  of  the  corium  and 
subcutaneous  connective  tissue,  beginning  with  an  inflammatory  starje, 
during  which  the  lymphatic  glands  become  swollen,  and  the  lymph- 
paths  through  them  permanently  blocked,  and  resulting  in  stasis  of 
the  lymph,  and  hypertrophy.  The  treatment  is  rest,  with  the  use 
of  the  elastic  bandage  for  a  long  period;  or  ligature  of  the  main 
artery  to  the  limb;^  the  chief  nerve  of  the  limb  has  been  divided 
with  good  results.'^ 

1  J.  M.  Carnochau.  2  x.  G.  Morton. 


320  OPERATIVE  SURGERY. 

12.  Soft  fibrous  or  connective  tissue  tumors  ^  are  composed 
of  a  very  tough,  somewhat  cedematous,  white  tissue,  and  are  usually 
covered  with  the  thin  papillary  layer  of  the  cutis;  on  the  surface 
there  are  almost  always  pointed  papillte.  Even  when  the  tumor  is 
developed  in  a  part  of  the  skin  which  normally  has  no  papillae, 
they  usually  hang  loosely  and  are  often,  distinctly  pedunculated;  the 
growth  is  slow,  free  from  pain,  anil  may  develop  into  enormous  tu- 
mors, and  may  be  multiple;  they  occur  towards  the  end  of  middle 
life,  and  are  often  found  in  women  on  the  labia  majora.  The  treat- 
ment is  extirpation. 

13.  Sarcomata '  of  the  skin  are  generally  spindle-celled,  and  may 
be  alveolar  or  melanotic;  they  usually  ulcerate  early,  without,  how- 
ever, extensive  destruction ;  they  develop  with  peculiar  frequency  after 
precedent  local  irritations,  especially  after  injuries;  cicatrices  are  not 
unfrequently  the  seat  of  these  tumors;  black  sarcomata  may  come 
from  irritated  moles.  The  diagnosis  is  often  difficult,  owing  to  the 
variable  characters  which  they  assume;  they  are  generally  of  slow 
growth,  free  from  pain,  occur  in  middle  life,  and  their  location  is  at 
irritated  points.     The  treatment  is  extirpation. 

14.  Epithelioma,  squamous,  of  the  skin,^  begins  as  a  flattened 
and  indurated  elevation  of  the  surface,  an<l  extends  progressively 
both  in  depth  and  superficial  area ;  when  it  reaches  a  certain  maxi- 
mum of  development  at  its  place  of  origin  it  breaks  open  at  this  point; 
the  somewhat  tuberculated  sui-face  grows  rough,  erosions,  fissures, 
and  holes  appear  in  great  numbers,  and  exude  a  white,  inodorous, 
pulpy  fluid  mixed  with  pus;  it  next  falls  in  at  its  centre,  and  a  hol- 
low is  produced  which  is  henceforth  marked,  either  liy  the  dried 
secretions,  or,  when  these  are  removed,  by  the  sloughy  shreds  of  the 
original  tissue;  it  now  has  a  hard  base,  and  hard,  raised  edges;  at 
the  periphery  the  infiltration  advances  into  the  neighboring  parts, 
while  in  its  centre  there  is  disintegration,  and  the  phenomena  of  re- 
pair.i  The  most  frequent  seat  is  the  face,  especially  the  cheeks, 
brow,  nose,  and  eyelid.'-;  the  genitals,  as  the  penis,  the  clitoris,  the 
neck  of  the  uterus.  The  treatment  is  extirpation  by  free  incision, 
for  this  variety  does  not  belong  to  the  most  malignant  group  of  mor- 
bid growths  ;  within  a  year  the  cicatrix  usually  becomes  the  seat  of 
a  new  analogous  growth,  but  cases  occasionally  occur  in  which  the 
disease  has  not  returned  after  radical  extirpation. 

II.   THE    HAIR  AND  GLANDS. 

1 .  Overgrowth  of  hair  ^   can   only  be   said   to  exist   in   hairy 
moles;    the^e  brown,  hemispherical  or  flattened  elevalions  seem  to 
offer   peculiar   facilities   for    the    most   luxuriant   growth   of   hair  ; 
1  T.  Billroth.  -  E.  Kiiidaeisch, 


DISEASES  OF  THE   TEGUMENTARY  SYSTEM.    321 


Fig.  252. 


not  only  are  tlit-  iiulividiial  hairs  very  stout,  but  tliey  arc  shed 
and  renewed  much  ufteiier  than  those  of  the  head  and  beard.  A 
vertical  section  shows  at  least  one  fourth 
i»f  the  hair-follicles  very  thickly  set  and 
furnislied  with  a  little  accessary  sac  occu- 
pied by  a  new  hair  in  a  more  or  less  ad- 
vanced stage  of  development.  When  the  //S^  St'  5*  ^ 
growth  is  a  serious  deformity,  excision  may 
be  practiced,  or  it  may  be  removed  by 
caustics,^  as  follows :  The  surface  being 
shaved,  apply  the  disk- shaped  cautery  at 
a  red  heat  on  the  surface  until  a  dark, 
brownish  eschar  is  produced;  then  immedi- 
ately apply  compresses  wet  in  ice-water, 
and  renew  them  frequently;  by  this  means 
the  patient  suffers  but  little  pain  on  coming  out  of  the  anaesthesia, 
the  eschar  se[)arates  in  due  time,  and  the  granulation  growth  is  kept 
level  with  the  neii^hboring  skin  by  the  application  of  nitrate  of  sil- 
ver. Or,  the  solid  caustic  potassa  may  be  rubbed  into  the  surface 
till  the  skin  ])ecomes  a  disorganized  pulpy  paste,  its  action  being 
checkcil  by  ililiited  vinegar. 

2.  Retention  of  secretions  of  the  hair-follicles  and  seba- 
ceous glands,'^  gives  rise  to  a  variety  of  affections  conmionly  known 
as  wens.  The  cause  of  retention  is  often  a  closure  of  the  hair-fol- 
licle by  over-secretion  of  epidermis  and  tumefaction  of  the  sub- 
epiderndc  connective  tissue  about  the  "mouth  of  the  hair-sac.  The 
retained  secretion  may  often  be  squeezed  out  when  it  assumes  the 
form  of  a  worm,  comedones ;  in  other  cases  it  has  the  appearance  of 
honey,  creating  another  variety,  meliceris.  The  treatment,  when 
they  become  large  and  troublesome,  is  extirpation;  the  dissection  need 
not  be  carefully  made,  as  it  is  not  necessary  to  preserve  the  sac  en- 
tire; when  the  capsule  is  reached  it  may  be  bi- 
sected and  each  half  removed  separately  by 
evidsion  ;  seize  the  edge  with  strong  forceps 
and  forcibly  detach  each  portion. 

3.  Acne  rosacea '  consists  of  retention  of 
secreted  matter  on  one  hand  and  a  perifollicular 
inflammation  on  the  other;  the  sac  of  connec- 
tive tissue  appears  to  be  converted  into  pus, 
while  hypersBtnia,  plastic  infiltration,  and  sup- 
puration follow  one  another  in  an  area  extendinij 

from  half  a  line  to  two  lines  from  the  follicle.    The  growths  have  as- 
sumed such  size  (Fig.  253)  by  liy])ertrophy  of  the  connective  tissue 

1  G.  Buck.  2  E.  Riudtieisch.  8  C.  "Wagner. 

21 


Fig.  253. 


322  OPERATIVE  SURGERY. 

as  to  require  excision.^  In  the  operation  for  the  removal  of  the 
tumors,  divide  the  pedunculated  ones  close  to  the  cartilage  ;  from 
the  sessile  growths  remove  slices  by  elliptical  inci>ions, 
and  dissect  out  from  under  the  skin  the  h}pertro])hied 
tissue,  care  being  taken  to  leave  sufficient  iiap  to  cover 
the  cartilage;  close  the  wounds  wi.h  fine  silk  suture. 
(Fig.  254.) 

II.     THE  NAIL. 

The  nail  consists  of  the  flattened  cells  of  the  papillae 

•p       nr-,        of  the  posterior  part  of  the  matrix,  and  of  the  mucous 

layer  of  the  beds  of  the  matrix ;  the  former  are  pushed 

forwards  along  the  beds  in  ridges,  and  the  latter  are  added  to  the 

under  surface  of  the  nail.^ 

1.  Inflammation,  acute,  may  follow  injiu-ies,  as  blows,  the  pene- 
tration of  sharp  bodies  ;  the  chronic  is  caused  by  syphilis,  eczema, 
psoriasis;  the  result  may  be  irregular  growth  of  the  nail,  or  its 
destruction  by  suppuration  and  ulceration;  in  unhealthy  children 
the  inflammation  may  be  followed  by  the  ulceration  of  the  matrix. 
The  treatment  should  be  to  relieve  the  inflammation  by  the  removal 
of  the  cause,  and  such  general  and  local  remedies  as  the  special 
conditions  demand. 

2.  Atrophy  and  hypertrophy  ^  depend  upon  the  same  condi- 
tions, namely,  general  diseases,  as  syphilis;  local  skin  affections,  as 
eczema,  psoriasis;  injuries,  as  pressure,  blows,  penetration  of  splin- 
ters, needles;  trades,  as  hatters,  gilders;  fungi,  as  favus.  In  atrophy 
the  function  of  the  matrix  is  diminished,  and  the  nail  may  become 
thin,  small,  narrow,  soft,  or  be  wholly  lost.  In  hypertrophy,  the 
functions  of  the  matrix  are  increased,  and  as  a  consequence  the  nail 
may  be  of  unusual  length  and  width,  appearing  as  if  too  small  for  its 
place  ;  or  the  substance  of  the  nail  may  be  thickened  throughout, 
but  most  consiilerably  in  front,  having  the  shape  of  a  chisel,  with 
its  thick  base  forward;  or  the  thickening  may  chiefly  affect  the 
middle  portion,  so  that  it  is  elevated  in  the  form  of  a  cone  or 
wedge  raised  in  a  shapeless  hump,  often  continued  in  a  long,  straight 
or  curved,  tap-shaped  excrescence.  The  treatment  of  these  affec- 
tions is  the  same  so  far  as  they  depend  upon  the  same  conditions. 
All  sources  of  local  irritation  should  first  be  removed;  syphilis  re- 
quires the  ordinary  general  treatment,  and  the  local  application  of 
mercurial  plaster  wound  round  the  ungual  segment  of  the  finger  or 
toe,  so  that  it  compresses  the  fold  of  the  nail.  Non-syphilitic  affec- 
tions require  the  same  treatment  as  in  other  parts,  but  special  effort 
iTOUst  be  made  to  secure  the  effect  of  the  remedies  upon  the  mati-ix 

1  C.  Wagner.  2  Virchow.  ^  x.  Anuandale. 


DISEASES  OF  THE   TEGUMENT ARY  SYSTEM.    323 


and  bed  of  the  iiiiil.  In  li\  pcrtropliy,  India  rubber  worn  upon  the 
part  soon  niaterates  the  ei)iderMiis  ami  diuiiiushes  hyi»erjeniia  of  the 
papillary  hiyer.^  The  local  treatment  should  aim  to  remove  such 
excrescences  as  are  deformities  and  annoyances,  by  means  of  scis- 
sors, the  knife,  bone-nippers,  or  a  fine  saw,  care  being  taken  not  to 
extract  the  nail  from  its  bed. 

3.  Ingrowing  is  a  curvinjf  downward  of  the  niarixin  of  the  nail, 
and  in  general  is  found  on  the  external  border  of  the  nail  of  the 
great  toe;  it  is  due  to  the  pressure  of  tight  boots  or  shoes,  and  espe- 
cially when  the  nail  is  hypertrophicd;  the  fold  of  the  nail  becomes  in- 
flamed, the  skin  ulcerates,  red,  spongy  granulations  ajipear,  and  the 
part  becomes  exquisitely  tender;  the  ulcerative  process  may  extend 
backward,  and  finally  the  matrix  and  the  whole  end  of  the  toe  may 
be  involved  in  the  iiillammation.  The  treatment  at  first  should  con- 
sist in  attempts  to  heal  the  ulcerated  point  where  the  nail  penetrates 
the  skin.  Of  the  various  methods  proposed,  select  the  following:  Cut 
dossils  of  charpie,  having  parallel  threads,  of  the  length  of  the  lateral 
fold  of  the  nail,  or  rather  larger  ;  lay  it  on  the  nail  ])arallel  with  the 
fold;  by  means  of  a  flat  probe  push  the  mass  down,  thread  by 
thread,  between  the  swollen  inflamed  fold  and  the  border  of  the  nail, 
so  as  to  completely  separate  the  skin  and  the  nail;  pad  around  the 
furrow  of  the  nail  with  charpie;  apply  long  strips  of  adhesive  plaster 
one  and  a  half  lines  wide  around  the  toe,  from  above  downwards  as 
reg.ards  the  inHamed  fold  ;  repeat  this  dressing  daily,  if  necessary.'* 
When  the  inflammation  involves  the  whole  fold  and  extremity  of  the 
toe,  extirpate  the  portion  of  the  nail  involved,  as  follows:  with  sharp 
pointed  scissors,  slit  up  the  nail,  (Fig.  250)  then  seize  the  oflfendinw 
portion,  and  with  a  slight  twist  remove  it  from  the  matrix ^  (Fill-  251). 
When  the  inflammation  extends  completely 
around  the  nail,  the  entire  nail  should  be 
removed  and  the  matrix  excised. 

4.  Onychia*   is  an  inflammation  of  the 
matrix  of  the  nail,  causing  ulceration,  and 
gradunlly  involving  the  soft  textures  around  ; 
it   is   sometimes   the   effect   of   injury,   but 
more  frequently  occurs  as  a  result  of  some 
unhealthy  state  of  the  constitution;  the  sim- 
pler forms  begin  with  the  usual  signs  of  in- 
flammation in  the  soft  textures  around  the 
nail,  which  become  red,  painful,  and  swol- 
len ;  the  nail  itself  becomes  affected,  and  its  margins  roughened  and 
displaced;   sup]>uratit)n  and  ulceration  follow,  and  a  sore  is  formed 
which  is  often  kept  in  a  state  of  irritation  by  the  uneven  margin  of 
1  Hebra.  2  Kaposi.  3  Dupuytren.  *  T.  Annandale. 


Fig.  250. 


324 


OPERATIVE  SURGERY. 


Fig.  257 


the  nail  pressing  against  it;  the  nail  is  loosened,  its  edges  and  root 
roughened  and  raised  up.  In  its  most  severe  form,  onychia  maligna, 
it  occurs  in  children,  generally  after  slight  injuries;  the  whole  soft 
textures  around  the  nail  and  at  the  extremity  of  the  fingei's  become 
red  and  swollen,  giving  it  a  bulbous  ap])earance  (Fig.  257)  ;  the  dis- 
charge is  thin  and  fetid,  the  nail  is 
loosened,  and  the  bone  may  be  ex- 
panded. In  the  mild  form  use  ni- 
trate of  silver  to  arrest  the  ulcera- 
tion, and  remove  the  nail  if  it 
keeps  up  the  irritation.  In  the 
severe  forms,  remove  the  nail  at 
once,  and  freely  cauterize  with 
caustic  potassa,  nitric  acid,  or  ni- 
trate of  silver.  The  nail  is  best 
removed  as  follows  :  The  patient 
being  under  an  anaesthetic,  thrust 
the  sharp  point  of  strong  scissors  under  the  nail  and 
through  the  matrix  (Fig.  255)  ;  now  seize  one  sec- 
tion of  the  nail  with  strong  forceps  (Fig.  256),  and  by  sudden  e ver- 
sion tear  it  from  its  position. 

5.  The  claw-like  nail,  onychogryphosis,  depends 
upon  a  hyper-plastic  state  of  the  entire  matrix  of  the 
nail  (Fig.  258);  the  long,  horizontal  papillte  furnish 
nearly  all  the  substance  of  the  nail,  which  is  no  thick- 
er at  the  finger-tip  than  at  the  edge  of  the  lunula ; 
this  gives  the  nail  its  ridged  appearance,  each  ridge 
corresponding  to  a  papilla.^  The  only  reliable  rem- 
edy is  complete  removal  of  the  nail  and  its  matrix, ^ 
with  such  general  treatment  as  the  case  requires. 

6.  Horny  growths  (Fig.  259),  resembling  exos- 
toses, sometimes  appear   at  the  margin  of  the  great 

toe,  and  create  much  suffering.     The  only  treatment  is  excision. ^ 

7.  Psoriasis  ^  appears  as  a  thickened,  rough,  scabrous,  and  un- 
usually convex  condition  of  the  central  portion  of  the  nail  ;  the  free 
edge  is  often  split,  and  the  cuticular  fringe  at  the  bottom  of  the  nail 
is  ragged  and  retracted;  the  whole  nail  resembles  the  concave  shell 
of  an  oyster.  If  it  is  caused  by  syphilis,  give  mercury  in  small 
doses  for  a  long  period ;  if  not  specific,  give  arsenic  with  a  tonic. 
The  appearance  of  the  nail  is  improved  by  smoothing  with  glass  or 
sand-paper;  or  by  friction,  with  dilute  acetic  acid. 

1  E.  Riiulfleisch.  2  T.  Brvant.  3  T.  Smith. 


Fig.  259. 


OPERATIONS  ON  THE  TEGUMENTARY  SYSTEM.  32o 


CHAPTER   XXIX. 


w 


y 


I 


I: 


GENERAL  OPERATIONS  ON  THE  TEGUMENTARY  SYSTEM. 

THE  SKIN. 

Thermometry^  is  gem'rally  practiced  upon  the  skin  to  determine 
br\  with  exactness  tiie  state  and  variations  of  /^^ 
bodily  temperature,  and  is  an  important  \  \ 
mechanical  aid  in  diagnosis.'^  Two  kinds 
of  instruments  are  now  employed,  one, 
h,  c.  to  be  used  in  enclosed  cavities,  and 
the  other,  a,  upon  the  surface  of  the  in- 
tegument. Many  varieties  of  the  former  in- 
strument are  now  in  use,  but  the  straight, 
self-registering,  clinical  thermometer  (Fig. 
2<!1)  is  recommended  for  general  use. 2 
Thermometers  are  also  made  with  spiral 
tubes  and  a  constriction  in  the  stem  a 
short  distance  from  the  bulb,  to  prevent 
the  index  from  passing  into  the  bulb  when 
Fig.  2G0.  jorking  the  instrument  to  bring  the  index 
below  the  normal.  An  indispensable  condition  for  accurate 
investigation  is  that  the  instrument  itself  be  accurate;  to 
determine  this  question,  the  thermometer  should  be  tested 
by  placing  it  in  a  water-bath  with  a  standard  thermometer 
and  the  variation  noted ;  as  the  glass  changes  by  use  it  is 
found  that  clinical  thermometers  change,  and  hence  it  is 
desirable  to  repeat  the  test  occasionally.  The  same  ther- 
mometer should  be  used  continuously  on  the  same  patient. 
Before  making  an  observation  of  the  temperature  of  the 
body,  the  thermometer  shoidd  first  be  examined  to  ascertain 
the  position  of  its  index  or  the  detached  portion  of  the  col- 
umn of  mercury  in  the  tube  separated  by  a  very  minute  por- 
tion of  air;  if  the  bulb  is  warmed  the  ascending  column  of 
mercury  will  be  seen  to  push  the  index  before  it,  but  not  to 
touch  it;  upon  cooling  the  bull),  the  column  withdraws  and 
leaves  the  index  at  the  maximmn  tem]ieratnre  attained  ;  pi^ogi. 
the  index  being  a  portion  of  the  column  of  mercury,  that 
end  of  it  most  distant  from  the  bull)  indicates  the  temperature:  if  the 
index    is   found    to   be   above   ninety-eight   degrees    Fahrenheit,  it 

1  C.  A.  WunderlicU.  ^  A.  L.  Loomis. 


I'd 


326  OPERATIVE  SURGERY. 

should  be  shaken   down  until   it  is  at  least  two  or  three  degrees 
below  that  point,  say  ninety-five  degrees. 

The  shaking  of  the  index  from  a  higher  to  a  lower  point  in  the  scale  of  the 
instrument  is  often  a  matter  of  some  difficulty;  there  are  three  ways  of  accom- 
plishing it.i  The  index  of  mercury  is  prevented  from  sliding  backwards  and 
forwards  in  the  tube  of  the  instrument,  as  each  end  of  it  is  raised  or  depressed, 
by  the  law  of  capillary  attraction;  to  overcome  this  it  is  necessary  to  give  to 
the  index  an  impetus  capable  of  counteracting  the  attraction  of  the  sides  of  the 
enclosing  tube;  this  may  be  done  b_v  holding  the  instrument  between  the  thumb 
and  index  linger,  about  the  upper  fourth  of  its  length  in  a  line  continuous  with 
the  arm,  then  raise  the  forearm  until  the  thermometer  is  as  high  as  the  shoulder, 
and  bring  it  down  with  a  rapid  swing  or  jerk  in  a  line  w'ith  the  body;  this  mo- 
tion, if  vigorouslv  executed,  will  have  the  effect  of  propelling  the  index  toward 
the  bulb  at  the  rate  of  two  or  more  degrees  for  each  movement;  this  should  be 
repeated  until  the  index  points  below  ninety-eight  degrees.  Another  method 
is  to  seize  the  tube  about  the  middle,  between  the  thumb  and  finger,  with  the 
bulb  downwards,  and  to  strike  the  wrist  or  edge  of  the  palm  of  the  hand  upon 
the  other  hand;  this,  if  sharply  done,  will  have  the  desired  effect.  There  are, 
however,  disadvantages  to  this  method.  When  in  cold  weather  the  mercury 
has  retreated  into  the  bulb,  and  the  thermometer  is  jerked  in  this  way,  the 
mercury  is  liable  to  be  forced  up  the  tube  and  there  form  one  or  more  indices ; 
but  a  more  serious  objection  is,  that  the  tube  may  be  split,  for  when  the  mer- 
ciiry  is  so  suddenly  forced  into  the  small,  empty  conical  chamber  above  the 
bulb,  in  a  quantity  and  at  a  speed  that  the  tube  cannot  relieve  it  quickly  enough, 
it  acts  like  a  wedge  and  produces  a  minute  tissure,  usually  in  a  line  with  the 
enamel.  If  this  fissure  exist,  the  tube  should  be  held  at  different  angles,  when 
it  will  be  seen  as  a  segment  of  Newton's  rings  extending  to  near  the  edge  of 
the  tube.  A  third  method  is  to  hold  the  thermometer  as  at  first  by  the  upper 
fourth  of  its  length,  between  the  thumb  and  finger,  but  horizontally  and  at  right 
angles  to  the  forearm,  then  bring  it  down  with  a  quick  rotation  of  the  wrist, 
somewhat  accelerating  the  motion  by  the  downward  action  of  the  arm  at  the 
same  moment. 

The  introduction  of  this  instrtiment  into  the  well-closed  axilla  ap- 
pears to  be  the  most  convenient  method  in  the  great  majority  of 
cases ;  its  use  in  this  situation  is  attended  by  scarcely  any  difficulties, 
and  no  objection  can  be  made  on  the  score  of  decency. 

The  application  of  the  instrument  in  the  inside  of  the  mouth  apparently  af- 
fords uncertain  indications,  because  the  cool  air  inspired  may  easily  lower  the 
temperature;  but  the  mouth  must  be  employed  when  other  parts  are  inaccessi- 
ble; taking  the  temperature  in  the  rectum  and  vagina  is  repulsive,  and  can  sel- 
dom be  repeated  often  enough,  and  is  to  be  resorted  to  only  in  infants,  in  the 
emaciated,  during  collapse,  and  other  special  circumstances. 

Use  it  as  follows :  If  the  axilla  is  wet  with  perspiration  wipe  it 
dry ;  press  the  arm  against  the  side  to  close  the  cavity  for  a  few  min- 
utes, all  clothing  being  removed  from  it;  warm  the  whole  instru- 
ment in  the  hand  to  85°  F.  or  90°  F. ;  now  place  the  bulb  deep  in 
the  axilla  behind  the  anterior  fold,  the  stem  inclining  upwards,  and 
1  T.  H.  Hawksley. 


OPERATIONS   ON  THE   TEGUMENTARY  SYSTEM.  327 


close  the  axilla  by  pressing  the  arm  firmly  against  the  chest  ;  the 
arm  should  he  firmly  held  in  position,  the  stem  being  lightly  eovered 
■with  the  clothing.  The  instrument  shouM  be  accurately  retaineil  in 
the  clo  cd  axilla  at  least  five  minutes:  on  removing  it  note  the  point 
of  elevation  or  depression  of  the  upper  end  of  the  column.  The 
circumstances  of  the  case  and  the  objects  sought  to  be  attaine<l  must 
decide  the  question  of  time  and  freriuency  of  the  observations;  it 
is  desirable  to  repeat  the  ol)servation  at  a  similar  time  each  day; 
usually  it  is  sullicient  to  make  the  observation  twice  daily,  which  is 
best  done  between  seven  and  nine  A.  M.,  the  period  of  probable  low- 
est daily  temperature,  and  in  the  evening,  between  four  and  six 
o'clock,  the  period  of  probable  highest  daily  temperature. 

The  surface  thermometer  must  have  its  broad  extremity  placed 
upon  the  part  to  be  examined,  and  be  held  in  position  about  five 
minutes. 

The  variations  of  temperature  and  rate  of  radiation  of  any  part  of  the  surface 
may  be  accurately  determined  by  the  thermoscope  (Fig.  262). i     It  consists  of 
a  glass  tube  seven   inches  long  with  a  minute  bore,  open  at  one  end,         <m 
and  terminating   at  the   other  in  a  bulb;   an  adjustable  scale  is  at- 
tached to  the  outside  of  the  tube.     Prepare  it  for  use  as  follows:  im- 
merse the  bulb  in  hot  water  to  rarefy  the  air  inside;  then  plunge  the 
open  end  into  cold  water  and  quickly  witiidiaw  it,  wiien  a  drop  or  two 
will  be  found  to  have  entered  the  tube,  and  will  form  a  water  index 
which  should  become  stationary  within  an  inch  or  two  of  the   bulb; 
adjust  the  scale,  bringing  its   lowest  tigure  on  a  level  with  the  top  of 
the  column  of  water  in  the  tube.     It  may  be  applied  to  any  surface, 
and   registers  the  volume  of  heat  escaping  by  radiation  and  the  ve- 
locity of  loss. 

2.  Rubefacients  produce  intense  irritation,  redness,  and 
congestion ;  their  effect  is  temporary,  and  in  proportion  to 
the  extent  of  surface  covered;  they  are  preferable  to  blisters 
to  arouse  the  system. ^ 

Mustard  is  used  in  the  leaf  with  vinegar,  as  essential  oil,  as  a  flour 
sprinkled  on  a  wet  cloth,  or  laid  on  paper  sinapisms,  or  as  common  p  -co 
paste,  made  by  adtling  water  of  the  temperature  of  90^  to  IbO-  F. 
Linseed  or  Indian  meal  may  be  added  to  diminish  its  action;  one  part  of  mus- 
tard to  sixteen  of  meal  will  make  a  slightly  irritating  poultice,  which  children 
with  acute  diseases  of  the  lungs  will  wear  continuously  with  great  benefit ;  re- 
move the  mustard  before  the  skin  is  broken,  wipe  the  surface  with  a  wet  cloth, 
and  dress  the  part  with  cotton-wool  or  well-oiled  cloth.  Make  the  application 
directly  to  the  skin  when  prompt  action  is  required,  but  interpose  a  thin  cloth 
when  more  permanent  effects  are  sought.  An  artificial  essential  oil  of  mustard 
may  be  used,  namely,  sulphocyanide  of  allyl  in  solution  in  alcohol,  one  to  fifty. 
Capsicum  may  be  used  in  a  poultice,  or  on  cloths  wet  with  a  strong  watery  solu- 
tion. 

Turpentine  is  a  highly  stimulating  application,  and  may  be  used  as  a  linimcut, 
1  E.  C.  Seguiu.  2  H.  c.  Wood. 


328  OPERATIVE  SURGERY. 

or  sprinkled  on  a  wet  cloth ;  it  reddens  the  skin  very  prompth',  and  the  sur- 
face re(iuires  no  other  attention.  Dry-cupping  draws  the  blood  to  the  skin, 
where  it  remains  many  hours,  relieving  deep-seated  congestion;  apply  the  cup 
with  an  exhaust  pump,  or  use  the  common  cupping-glass,  or  a  small  tumbler, 
or  other  accessible  cup;  moisten  the  internal  surface  with  pure  alcohol;  ignite 
with  a  biu'ning  wisp  of  paper,  and  invert  the  cup  on  the  part.  Crofon  oil  causes 
a  fine  pustular  eruption,  and  is  applied  by  rubbing  briskly  one  part  of  oil  to  three 
parts  of  olive  oil,  and  repeating  carefully,  limiting  it  to  the  part.  Potassio-tar- 
trate  of  antimony,  tartar  emetic,  causes  a  large  pustular  eruption,  and  is  applied 
as  an  ointment,  well  rubbed  into  the  skin ;  the  surfaces  are  to  be  dressed  as 
after  the  application  of  mustard.  The  strong  tincture  of  iodine  repeated  sev- 
eral times,  and  nitrate  of  silver,  in  concentrated  solution,  or  mixed  with  lard, 
produce  desquamation. 

3.  Vesicants  are  more  permanent  in  their  effects  than  rubefa- 
cients ;  their  local  action  consists  in  first  diminishin<jj  and  then  de- 
stroying the  vitality  of  parts  with  which  they  are  brouuht  in  contact; 
tliis  local  action  is  depletory,  as  by  increasing  the  amount  of  blood 
in  the  tissues  immediately  under  the  blistered  surface,  the  deeper 
subjacent  structures  are  rendered  very  anasmic;  they  also  affect  the 
heart  through  the  nervous  system,  the  weak  applications  strengthen- 
ing, and  the  powerful  depressing  its  action.^ 

There  are  manj'  agents  which  may  be  made  to  act  as  vesicants,  as  canthari- 
des,  ammonia,  liot  fluids.  Cantharides  acts  most  promptly  on  the  young,  and 
on  parts  where  the  integument  is  thin.  It  may  be  used  in  the  form  of  blistering 
liquid,  cantharidal  collodion,  applied  with  a  brush,  or  of  tissue,  or  of  the  offi- 
cinal emplast  cantharis.  The  surface  to  which  it  is  to  be  applied  should  be 
cleansed,  and  if  there  is  liability  to  strangury,  dusted  with  camphor,  or  covered 
with  oiled  tissue-paper.  Fresh  cantharides  will  vesicate  within  three  to  five 
hours;  if  not  fresh,  vinegar  applied  to  the  skin  or  plaster  will  often  hasten  its 
action.  The  redness  of  the  surface  and  snuill  blisters,  are  evidence  of  the  ac- 
tion of  the  vesicant;  the  application  of  cloths  wrung  out  of  hot  water,  or  a 
poultice,  causes  immediate  effusion  of  serum;  open  the  blister  with  a  needle  at 
tlie  most  depending  part;  allow  the  cuticle  to  fall  upon  the  surface  underneath; 
dress  the  surface  with  oil  or  simple  cerate.  To  make  the  effects  of  the  blister 
more  permanent,  remove  the  cuticle  and  apply  stimulating  substances,  as  the 
leaf  of  the  cabbage,  beet,  ivy,  or  savin  ointment.  To  vesicate  quickly,  apply 
chloroform  on  cotton  covered  by  a  watch-glass  or  saucer;  or  liquid  ammonia  on 
a  swab,  or  hot  water.  A  heated  iron,  thermal  hanmier,  dipped  in  water  of 
120^  F.  and  applied  to  the  skin  two  or  three  seconds,  is  a  rubefacient,  and  con- 
tinued five  to  ten  seconds  is  a  vesicant.  If  excessive  inflammation,  or  erysipelas, 
follow  the  blister,  apph'  poultices  of  bread  and  water  or  tiax-seed. 

4.  The  endermic  application  -  of  remedies  is  fre(|uently  prefer- 
able to  administration  by  the  stomach  or  hypodermically.  The 
method  consists  in  introducing  the  substance  into  the  skin  by  rub- 
bing, inunction,  or  occasionally  it  will  be  useful  to  remove  or  to  irri- 
tate the  cuticle,  and  to  apply  the  remedy  to  the  denuded  or  reddened 
spot.     Mor])hiiu'  .■lud  (juiiiinc  may  be  thus  applied;  but  they  must  be 

1  A.  W.  Ilollis.  2  w.  Bernatzik. 


OPERATIONS   ON   THE   TEGUMENT ARY  SYSTEM.   329 


Fig.  2()o. 


used  in  quantities  about  one  third  larger  than  wlien  apjilied  hyj)o- 
derniicalh-.  Mercurials  are  generally  applied  to  the  unbroken  skin, 
for  instauee,  the  ung.  hydr.,  or  ung.  hydr.  nitrat.,  or  the  oleate  of 
niereurv.  Solutions  of  alkaloids  in  oleic  aeid,  sueh  as  the  oleates 
of  morphia,  aeonitia,  veratria.  atro])ia,  and  quinia,  are  very  readily 
absorbed.  The  quantities  usually  employed  for  a  single  applieation 
are  the  following:  morphia,  one  sixth  to  one  half  grain;  veratria,  one 
twelfth  to  one  third  grain :  stryehnia,  one  twentieth  to  one  twelfth 
f^rain;  atropia  and  hyoseyamia.  one  sixtieth  to  one  twentieth  grain. ^ 

5.  Acupiincture  is  a  method  of  eounter-irritation  effected  by 
passing  slender  needles       ^  

into  the  jjurt,   and  al-    q  

lowing  them  to  remain 

from  a  few  minutes  to 

several     hours.        The 

needle  shouKl  be  of  steel,  from  two  to  four  inches  in  length,  polished, 

very  sharp-pointed,  lle.xible,  and  soft,  having  a  metallic  head.     (Fig. 

263.) 

They  are  inserted  by  making  the  skin  tense  with  the  left  hand,  and  with  the 
right  introducing  the  needle,  with  a  rotatory  motion,  to  the  required  depth, 
avoiding  joints  nnd  viscera.  Tliey  may  safely  penetrate  several  inches,  and 
have  even  been  introduced  into  viscera  without  ill  effects.  They 
are  liable  to  become  oxidized,  and  on  removing  them  pressure 
should  be  made  upon  the  adjoining  surface,  while  the  needle  is 
rotated  slightly. 

An  instrument  has  been  devised  to  introduce  a  vesicatory  liquid 
beneath  the  epidermis.-  The  piston  containing  the  needles  is  ad- 
justable in  its  cylinder,  which  holds  the  medicinal  preparation; 
the  needles  project  through  the  diaphragm  to  the  required  extent, 
and  the  cpispastic  liquid  insinuates  itself  along  with  the  needles 
into  the  punctures.  Another  form  of  acupuncturator  ^  (Fig.  -264) 
has  a  regulating  nut,  (7,  to  adjust  the  depth  of  penetration  of 
the  needles  which  ]>roject  through  the  diaphragm  to  conduct  the 
liquid  from  the  cylinder  ^1  and  introduce  it  through  the  skin;  the 
needles  h,  e,  are  stacked  in  the  piston  B,  whose  stem  d  is  sleeved 
in  the  stem  screw  c,f.  ^  Pig.  264. 

6.  The  issue  is  a  suppurating  wound  of  the  deeper  structures  of 
the  skin.  It  may  be  made  with  a  seton,  incision,  caustic,  or  moxa, 
and  must  be  so  limited  as  not  to  extend  its  action  beyond  the  subcu- 
taneous areolar  tissue.  Apply  them  at  points  as  free  as  possible 
from  local  irritation,  and  remote  from  large  vessels  and  nerves,  as 
the  nape  of  the  neck,  the  insertion  of  the  deltoid  on  the  arm,  the 
external  part  of  the  thigh  and  internal  part  of  the  leg.  The  seton 
may  consist  of  a  few  threads,  a  piece  of  linen,  or  of  lamp-wicking, 
or,  what  is  now  more  frequently  used,  on   account  of  cleanliness,  a 

1  C.  Rice.  '  Fiermenich.  8  Klee. 


330 


OPERATIVE  SURGERY. 


strip  of  In(lia-rul)ljer  cloth.  The  instruments  required  for  its  intro- 
duction are  either  the  seton  needle  (Fig.  260)  or  a  straight 
bistoury,  and  a  probe  having  an  eye.  Pinch  up  a  fold  of 
the  skin  corresponding  with  the  direction  of  the  muscles  of 
the  part,  or  vertical  with  the  body,  pass  the  needle,  armed 


\> 


Fig.  265.  Fig.  260.  Fig.  207. 

with  the  seton,  deeply  through  the  parts,  but  without  involving  ten- 
dons or  muscles;  draw  the  seton  through  and  tie  loosely.  If  the  bis- 
toury and  eyed-probe  are  used,  pinch  up  the  integuments  and  trans- 
fix with  the  bistoury  (Fig  266);  pass  the  probe  having  the  seton 
through  the  eye,  or  attached  by  a  thread  (Fig.  267),  through  the 
wound,  and  tie.  The  subsequent  dressings  consist  of  greased  lint, 
and  a  bandage  around  the  part  to  be  exchanged  for  a  poultice  when 
suppuration  commences.  The  seton  must  be  drawn  through  daily, 
and  the  part  saturated  with  pus  cut  off.  When  an  issue  is  made 
with  the  knife,  the  incision  must  penetrate  into  the  subcutaneous 
cellular  tissue,  and  a  foreign  body,  as  a  pen,  or  a  small  bead,  is 
introduced  and  retained  by  adhesive  straps  until  suppuration  is  es- 
tablished. The  caustic  may  be  the  actual  cautery,  or  Vienna  paste, 
or  other  powerful  escharotics.  In  shape,  the  iron  cautery  should 
have  a  more  or  less  flattened  surface,  wheri  it  is  required  to  produce 
a  superficial  slough,  or  conicnl  when  it  is  re- 
quired to  penetrate  more  deeply  (Fig.  268).  If 
it  is  applied  at  a  white  heat,  and  firmly  pressed 
upon  the  part  until  an  eschar  is  formed,  although 
not  severely  painful,  local  anaesthetics  should  be 
used;  cold-water  dressings  should  be  ap])lied  for 
several  hours,  followed  by  moist  warm  applications,  as  a  poultice, 
until  the  slough  se[)arates.  Vienna  paste  is  prepared  by  triturat- 
ing equal  parts  of  quicklime  and  caustic  potassa;  it  is  applied  to  the 
part,  of  ilie  re(|uired  size,  and  allowed  to  remain  ten  or  fifteen  min- 
utes; when  removed,  wash  the  surface' with  dihited  vinegar,  to  coun- 
teract its  action.     Caustic  potassa  may  be  used  in  a  similar  manner, 


Fig.  268. 


OPERATIONS  ON  THE  TEGUMENTARY  SYSTEM.  331 


the  parts  Iieinjj;  circumscribed  by  a  piece  of  adhesive  plaster,  through 
an  opening  in  which  the  application  is  made.  Strong  sulphuric  acitl 
also  makes  an  issue  of  the  piopcr  depth,  its  effect  being  controlled 
by  an  alkali.  The  subsequent  dressings  are  poultices.  The  moxa  is 
a  combustible  substance,  burned  upon  the  surface;  it  may  be  com- 
posed of  lint,  carded  cotton,  hemp,  agaric,  etc.,  or  the  lint  may  be 
saturated  with  the  nitrate  of  potassa.  The  substance  selected  should 
be  firndy  rolled  into  a  pyramidal  form,  and  held  together  by  threads, 
or  a  solution  of  gum  araltic,  an  inch  or  an  inch  aiul  a  half  long,  and 
of  a  diameter  at  the  base  corresponding  with  the  size  of  the  proposed 
eschar.  Local  anajsthesia  being  produced,  the  moxa  is  held  in  posi- 
tion with  forceps  or  wire,  and  is  ignited  at  the  top;  as  it  burns 
down,  any  desired  degree  of  irritation  can  be  obtained,  from  a  sim- 
ple redness  to  a  deep  eschar,  according  to  the  time  it  is  maintained 
in  contact  with  the  skin. 

7.  Hypodermic  iujec'don  is  a  method  of  inserting  remedies  into 
the  subcutaneous  areolar  tissue.  Its  advantages  are,  rapidity  of  ac- 
tion;  intensity  of  effects;  economy  of  material;  certainty  of  action; 
facility  of  introduction  in  certain  cases;  with  some  drugs  the  avoid- 
ance of  unpleasant  symptoms.^  The  apparatus  required  is  a  hypo- 
dermic syringe,  needles,  and  solutions. 

The  syringe  consists  of  a  barrel  and  rod,  and  a  canula  of  silver  or  steel,  which 
has  a  point  for  pene- 
tration and  an  opening 
for  injection  of  the  liq- 
uid (Fig.  269);  n,  b,  c, 
is  a  form  with  a  glass 
tube,  a  graduated  rod, 
and  deiaciiable  points 
of  two  shapes;  d,  e,  is 
a  form  of  hypodermic 
syringe  to  be  carried 
in  a  pocket-case;  the 
point,  inclosing  the 
wire-cleaner,  fits  into  lE^pt 
a     hollow     graduated  ^  .    £,„„ 

piston;    the    barrel    is 
an  ordinary  silver  tube,  the  size  of  No.  10  catheter,  and  is  six  inches  long. 

There  are  numerous  cases,  varying  in  size  to  suit  the  convenience 
of  practitioners.  To  meet  the  increasing  necessities  of  this  form  of 
medication  the  case '^  should  contain  a  double  fenestrated  hypodermic 
syringe  ;  three  needles  of  different  sizes,  the  smallest  being  the  most 
delicate  manufactureil,  the  second  larger,  and  the  third  of  the  ordi- 
nary size  ;  extra  leather  washers  and  wires  for  keeping  the  tube  open 
and  clean;  a  small  hone  of  the  finest  quality  for  sharpening  the 
1  Com.  on  Hypodermic  Method.  2  \v.  \,  Greene. 


oQ^3= 


332 


OPERATIVE  SURGERY. 


points;  a  twenty-four  minim  glass  measure  perfectly  exact;  five  two- 
drachm  vials  filled  as  follows:  (1)  sol.  sulpli.  morphia,  16  grs.  to  the 
ounce,  or  ^  gr.  to  15  m. ;  (2)  sol.  sulph.  morphia,  8  grs.  to  the  ounce, 
for  children,  or  delicate  females;  (3)  sol.  atrojiiiie,  I  gr.  to  the  ounce; 
(4)  strong  alcohol  for  cleaning  the  points;  (5)  fluid  ext.  ergot.  The 
case  may  contain  other  solutions,  a  thermometer,  and  thumb  lancet. 
It  is  not  necessary  to  confine  the  injection  to  the  painful  part,  and 
thus  a  tendency  to  abscess  from  repeated  injection  may  be  avoided.^ 
As  a  rule,  the  least  pain  and  irritation  is  caused  when  the  injection 
is  made  at  or  near  the  insertion  of  the  deltoid,  or  in  front,  between 
the  ribs  and  hip  bone,  or  from  near  the  spine  to  the  median  line. 
Operate  thus  :  On  the  first  trial  always  use  a  minimum  (juantity  of 

the  drug ; -  draw 
the  required 
amount  into  the 
syringe ;  elevate 
the  point  of  the 
needle  and  force 
out  a  di'op  to  ex- 
FiG.  270.  pel  the  air;  pinch 

up  the  skin  at  the  point  selected  and  thrust  tlie  needle  into  the  sub- 
cutaneous connective  tissue,  avoiding  any  veins  apparent;  now  gently 
force  the  fluid  out  drop  by  drop,  watching  its  effects;  if  no  effect  is 
produced  when  the  last  drop  is  injected,  withdraw  the  needle  in- 
stantlv  and  press  the  finger  on  the  puncture  for  a  moment;  if  faint- 
ness  or  other  unusual  sym])tom  appear,  withdraw  the  needle  and  ap- 
ply such  restoratives  as  may  be  required.     (Fig.  270.) 

The  needle^  may  be  little  larprer  than  the  proboscis  of  a  fly,  so  delicate  in  fact 
that  fluids  as  thin  as  water  barely  pass  through  it,  and  tliat  quite  slowly;  it  will 
penetrate  the  skin  and  reach  the  cellular  tissue  without  pain,  the  little  child  and 
delicate  female  not  being  aware  of  its  introduction  in  the  cervical  and  lumbar 
spinal  regions,  or  about  the  insertion  of  the  deltoid.  The  needle  should  not  screw 
on,  but  slide  in,  and  thus  avoid  the  wearing  of  the  screw  and  the  destruction  of 
the  thread.  To  keep  the  leather  washer  of  the  piston  alwavs  damp,  draw  a  few 
drops  of  water  into  the  barrel  after  using  it,  and  let  it  remain;  when  about  to 
use  the  syringe,  draw  this  water  out,  and  the  piston  will  work  well.  Prepare 
the  solution  of  morphia  sulph.  by  putting  four  grains  in  the  vial  and  tilling  it 
with  hot  water;  no  acid  is  required  to  make  and  keep  this  a  perfect  solution; 
it  is  generally  required  in  an  emergency,  and  should  always  be  in  the  case;  it 
keeps  indefinitely.  To  clean  points  draw  the  alcohol  up  and  force  it  out  of  the 
tube  several  times;  then  detach  the  point  and  blow  tiirough  the  tube  ;  finallv, 
pass  the  wire  through,  wiping  it  every  time  it  is  withdrawn,  after  which  leave 
the  wire  in  the  point. 

8.  Vaccination  destroys  or  diminishes  susceptibilit}'  to  variola; 
every  practitioner  is  under  imperative  obligation  to  exercise  reason- 
i  C  Hunter.  2  ic.    £.  Anstie.  3  w.  A.  Greene. 


OPERATIONS  OX  THE  TEGUMEXTARY  SYSTEM.  333 

able  tare  aiul  ililii^eace  in  the  protection  by  this  means  of  all  persons 
subject  to  his  professional  advice  and  eare.^  It  may  safely  be  per- 
formed at  any  period  of  life,  and  no  age  shotdd  exempt  a  person 
from  vaccination  who  has  been  exposed  to  sniall-j)Ox;  the  most  suit- 
able period  is  six  weeks  from  birth,  and  it  should  not  be  delayed  be- 
yond the  third  month,  unless  conditions  unfavorable  arc  unavoidably 
present,  as  acute  febrile  diseases  or  vesicular  eruptions.^ 

The  practitioner  is  responsible  for  the  purity  of  the  lymph  which  he  uses,  for 
pure  virus  can  cause  no  otlier  disease  than  variola;  diseases  are  invaccinated 
only  when  the  lynipli  is  contaminated  with  blood,  pus,  or  otiier  carriers  of  cou- 
tagia.- 

Lyniph  is  of  two  kinds,  human  or  bovine,  accordingly  as  it  is 
taken  frotn  man  or  animal.  Humanized  virus  must  be  selected  from 
children  of  healthy  parentage,  and  free  from  all  hereditary  taint, 
and  cutaneous  or  other  discoverable  affections.  In  the  collection  of 
lymjdi,  the  following  rules  should  be  observed^  :  — 

The  vesicles  should  be  perfect,  having  passed  througli  all  the  stages  without 
complications.  Lymph  must  be  taken  from  the  vesicle  before  the  areola  has 
formed,  the  most  favorable  period  being  the  eighth  day,  or  day  week  after  vac- 
cination. Several  fine  punctures  should  be  made  in  the  top  of  the  vesicle,  when 
the  lymph  will  exude  from  the  cells  and  may  be  taken  for  immediate  use,  or  for 
preservation.  The  vesicle  should  never  be  squeezed  to  obtain  more  lymph,  but 
the  surface  may  be  gently  wiped  with  a  wet  doih  to  remove  any  obstruction  of 
the  puncture.  If  any  blood  appear  it  must  be  allowed  to  coagulate,  and  then 
be  removed,  before  lymph  is  again  taken.  The  virus  may  be  taken  on  points, 
pieces  of  ivory,  or  quill  scraped  smoothly,  two  coats  being  applied ;  or  in  capillary 
glass  tubes  into  which  the  lymph  is  drawn  by  capillary  attraction,  and  which  are 
then  sealed  at  both  ends  by  the  flame  of  a  caudle,  to  the  exclusion  of  the  air. 
The  lymph  is  frequently  preserved  in  the  scab,  or  crust,  which  is  the  dried  ves- 
icle. This  falls  between  the  twentieth  and  twenty-fifth  days,  is  of  a  mahogany 
or  amber  color,  and  semi-transparent.  If  there  is  pus  or  blood  in  the  scab,  that 
portion,  or  the  whole,  should  be  rejected.  The  virus,  in  whatever  form,  must  be 
preserved  from  the  air,  and  in  a  cool  place. 

Vaccination  may  be  successfully  performed  on  any  part  of  the 
body;  but  for  convenience  and  freedom  from  irritation,  the  arm  near 
the  insertion  of  the  deltoid  muscle  is  ordinarily  selected.  The  left 
arm  is  preferred  to  the  right,  in  first  vaccination,  as  it  is  not  so  much 
used.  Though  the  operation  is  extremely  simple,  it  requires  great 
care  and  delicacy  in  its  performance.  A  variety  of  instruments  have 
been  used,  but  a  common  lancet,  slightly  dull,  answers  every  indica- 
tion. It  should  be  kept  in  a  state  of  perfect  cleanliness,  as  rust  or 
filth  are  liable  to  poison  the  wound.  After  each  vaccination  it 
should  be  cleaned  with  a  wet  cloth.  The  operator  should  grasp  the 
arm  so  as  to  make  the  skin  tense  at  the  i)oint  of  insertion  of  the 
virus,  and  either  make  several  punctures  with  the  point  of  the  lan- 
1  E.  C.  Seaton.  2  J.  Simon.  »  J.  B.  Taylor. 


334  OPERATIVE  SURGERY. 

or  several  incisions  (Fig.  271),  thus  11|||,  or  abrasions, 
thus  ^.  The  lancet  should  penetrate  sufficiently 
to  cause  the  appearance  of  blood.  If  the  virus  is 
taken  from  another  arm,  the  point  of  the  lancet 
should  be  charged  by  uncapping  cautiously  one  of 
the  cells  of  the  vesicle.  If  the  quill  is  used,  first  wet 
the  charged  extremity  with  a  drop  of  water.  If  the  scab  is  used, 
dissolve  a  small  portion  in  a  drop  of  water  or  glycerine  on  a  piece 
of  glass,  and  charge  the  point  of  the  lancet.  VV^hatever  form  of 
virus  is  used,  be  careful  to  rub  the  l3mpli  well  into  the  abrasions; 
the  flow  of  blood,  though  considerable,  does  not  interfere  with  the 
success  of  the  operation. 

The  following  facts  i  in  regard  to  the  progress  of  successful  vaccination,  and 
the  complications  which  may  arise,  are  important:  After  the  inoculation,  a 
period  of  inaction,  comprising  three  or  four  days,  is  followed  b}'  a  papule-like 
elevation  of  the  skin,  due  to  swelling  of  the  cells  of  the  deep  layers  of  the  epi- 
dermis, accompanied  by  hypersBmia;  these  cells  continue  to  enlarge,  and,  by 
the  tifth  or  sixth  day,  the  pock  is  found  augmented  in  size,  and,  from  inci'eased 
distention  of  the  cells,  presents  the  appearance  of  a  vesicle,  with  a  central  de- 
pression, and  is  multilocular  in  structure.  The  contained  fluid  {vaccine  lymph) 
is  a  colorless,  adhesive  liquid,  containing  leucocytes  and  minute  granules,  in 
which  latter  resides  its  virulent  propert}'.  The  papillary  layer  of  the  derma  is 
novv  invaded  by  the  morbid  process;  tlie  free  ends  of  the  papillae  become  stran- 
gulated by  cell-impaction,  and,  melting  down,  mingle  with  tiie  fluid  contents 
of  the  pock.  Occasionally,  the  disease  extends  completely  through  the  derma, 
and  involves  the  subjacent  cellular  tissue,  which  then  shares  the  fate  of  the 
destroyed  papilliB.  On  the  eighth  day  (inclusive)  the  pock  has,  if  it  have  been 
produced  by  long-humanized  virus,  acquired  its  greatest  size;  if  it  have  been 
produced  by  bovine  virus,  or  by  humanized  virus  of  early  removes,  it  continues 
to  increase  in  size  for  several  days  longer.  On  the  ninth  day  the  pock  has  in- 
creased in  plumpness,  its  central  depression  is  more  marked,  a  brown  incrusta- 
tion has  begun  at  the  centre,  the  fluid  contents  are  more  decidedly  purulent, 
and  the  whole  is  surrounded  by  a  sharply-detined,  bright  redness  of  the  skin, 
extending  over  a  disk  of  from  one  to  two  inches  in  radius,  and  techiiicallj' 
called  the  areola.  In  the  human  subject  the  areola  is  usually  accompanied  by 
febrile  reaction ;  but  in  the  calf  there  is  no  areola,  and  but  little,  if  any,  constitu- 
tional reaction.  The  further  progress  of  the  disease  consists  in  the  gradual 
fading  of  the  areola,  with  the  transformation  of  the  entire  pock  into  a  hard,  dry, 
translucent  brown  crust,  which  separates  some  time  between  the  fifteenth  and  the 
thirty-second  days,  leaving  a  more  or  less  depressed  cicatrix,  which  is  usuall}' 
permanent,  and  which  shows  numerous  lesser  depressions,  which  give  it  the  ap- 
pearance termed  foveolation.  If  the  individual  have  previously  had  the  disease, 
it  usually  runs  a  more  rapid  and  less  regular  course,  although  the  inflammation 
is  apt  to  be  more  marked.  Vaccinia  usually  runs  its  course  without  complica- 
tions, and  does  not  call  for  treatment.  Excessive  erythema  is  best  treated  by 
the  application  of  a  liniment  composed  of  Sij  of  ung.  stramonii,  3j  of  liq. 
plumb,  subacetat.,  and  3  viij  of  linseed-oil.  True  erysipelas  is  very  rarely 
caused  by  vaccination,  and  does  not  require  a  moditied  treatment.  Axillary 
1  F.  R.  Foster. 


OPERATIONS  ON  THE   TEGUMENTARY  SYSTEM.  335 

adenitis  is  common,  and  should  be  treated  on  general  principles.  The  same  is 
true  of  cellulitis.  Ulceration  of  the  pock  (generally  caused  by  vioience)  may 
be  treated  by  sprinkling  with  eqiial  parts  of  powdered  starch  and  oxide  of  zinc, 
and  the  same  may  be  used  to  check  an  immoderate  flow  of  lymph,  after  open- 
ing the  pock  for  the  purpose  of  obtaining  virus.  The  conveyance  of  syphilis  in 
vaccination  may  be  certainly  prevented  by  complying  with  all  of  the  following 
rules:  (1)  Use  only  bovine  virus,  or  humanized  virus  which  is  known  to  be  free 
from  syphilitic  virus;  (2)  after  once  applying  the  lancet,  or  other  instrument, 
to  the  vaccinee,  it  should  on  no  account  be  again  applied  to  the  vaccinifer, 
or  any  other  |)erson,  until  it  has  been  thoroughly  cleansed;  (3)  after  once  using 
a  quill  slip,  throw  it  away.  Vaccination  generally  confers  complete  and  lasting 
protection  against  small-pox;  any  person  may,  however,  constitute  an  excep- 
tion. Hence,  every  individual  should  be  revaccinated  as  often  as  once  in  five 
j'ears,  and  whenever  small-pox  is  present  as  an  epidemic,  or  upon  setting  out 
on  a  voyage,  or  when  al)out  to  undertake  military  duty.  As  a  rule,  revaccina- 
tion  succeeds.     It  should  be  carefully  done,  and  repeated  if  unsuccessful. 

9.  Transplantation  of  skin  is  frequently  required  to  repair  de- 
fects either  cuii<ieiiital  or  due  to  injuries  and  diseases  which  cause 
destruction  of  integument.  These  operations  are  chieHj  confined  to  . 
the  face  and  joints,  and  have  for  their  s|)ecial  and  uhiinate  ohject 
the  relief  of  the  disfiL'iireinents,  and  the  restoration  of  function  of  the 
parts  involved,  as  of  the  mouth,  or  nose,  or  eye.  Innumerable  spe- 
cial operations  have  been  j)Iaiined  and  executeil  to  meet  the  ever- 
varying  indications  which  these  deformities  present;  but  there  are 
certain  underlying  principles  which  should  always  govern  tlie  pro- 
cedure, whatever  method  may  be  ailopted.  The  object  ^  in  all  cases 
is  to  obtain  union  by  first  intention,  and  to  eflfect  this  purpose, 
(1)  the  flap  must  be  of  such  ample  size  that  subsequent  shrinking 
will  not  interfere  with  the  perfection  of  the  cure;  (2)  there  must  be 
no  effusion  of  blood  forming  a  clot  under  the  flap;  (:?)  the  margins  of 
the  flap  must  be  held  accurately  together  with  the  smallest  amount 
of  irritation.  The  more  inq)ortant  features  of  the  operation  are  as 
follows:  2  (1)  in  the  choice  of  skin,  select  that  which  is  normal  and 
in  healthy  condition;  dispose  the  patch  of  skin  to  be  transferreil  so 
that  its  long  axis  corresponds  to  the  direction  in  which  the  arterial 
vessels  are  distributed,  and  the  free  extremity  of  the  patch  towards 
their  destination;  (2)  to  secure  precision  in  adapting  a  patch  of  skin 
to  a  new  locality  to  which  it  is  to  be  transferred,  first  prepare  the 
space  to  be  filled  by  paring  its  edges  and  dissecting  them  up  sulH- 
ciently  from  their  underlying  connections  to  allow  of  their  eversion; 
cut  from  oiled  silk  an  exact  pattern  of  the  space  and  apply  it  to  the 
surface  which  is  to  supply  the  new  material;  insert  small  pins  at  in- 
tervals around  the  pattern,  at  a  distance  of  one  line  from  the  margin, 
as  an  allowance  for  shrinkage,  but  a  larger  allowance  must  be  made 
for  the  length,  so  as  to  permit  the  patch  to  be  brought  around  edo-e- 
1  T.  Holmes.  a  G.  Buck. 


336 


OPERATIVE  SURGERY. 


wise  without  strain.  The  methods  of  tran.sfer  of  the  skin  are  as  fol- 
lows: (1)  By  approximation  ;  when  the  skin  is  supple  and  movable 
on  both  sides  of  the  space,  pare  the  opposite  edges,  dissect  up  the 
adjacent  skin  to  a  suliicient  distance  to  permit  their  meeting  and 
beino-  secured  by  sutures ;  if  there  is  too  much  strain,  make  incisions 
through  the  skin  parallel  with  the  wound;  (2)  by  sliding;  if  upon 
one  side  only  the  skin  is  sound,  prepare  the  space,  and  dissect  up 
a  patch  of  the  required  size  in  the  healthy  skin;  glide  this  patch 
edgewise  over  the  space,   and  attach  its  edges  by  sutures;  (3)  by 


Fig.  272.1  Fig.  273.1 

transfer  to  a  distance;  this  is  done  either  by  transferring  the  patch 
edgewise,  but  making  its  pedicle  describe  a  part  or  the  whole  of  a 
semicircle;  or  by  jumping  over  intervening  tissue,  and  severing  the 
pedicle  when  union  has  taken  place.  The  raw  surface  left  after 
transfer  of  a  patch  should  first  be  covered  with  scraped  lint,  and 
then  with  lint  saturated  with  collodion;  a  crust  forms  which  only 
separates  to  leave  a  healthy  granulating  surface.  The  suture  used 
may  be  (1)  the  interrupted  thread;  the  needle  should  be  trocar- 
pointed;  the  glove-makers' thread  answers  as  well  as  wire;  insert  the 
needle  obliquely  from  the  edge  backward  so  that  the  suture  will  have 
a  tendency  to  evert  the  edges  of  the  wound;  insert  sutures  enough 
to  secure  exact  coaptation,  for  multiplicity  is  not  objectionable;  (2) 
the  common  figure-of-eight ;  (3)  the  beaded  wire  clamp  as  an  auxil- 
iary for  the  support  of  other  sutures.^ 

In  many  instances  these  several  sutures  may  be  required  in  differ- 
ent parts  of  the  same  flap  or  flaps,  depending  upon  the  degree  of 
tension  of  the  parts.  The  beaded  wire  clamp,  however,  when  the 
tissues  are  in  suitable  condition,  is  more  available  than  the  others, 
being  easily  applied,  and  very  powerful  in  retaining  the  flaps  in 
exact  apposition. 

This  consists  of  silver  wire  with  a  glass  bead  on  the  extremity,  held  in  place 

by  a  disk  of  leatiier;  the  wire  being  drawn  through  the  two  sides  at  the  desired 

point,  another   bead   is   slipped  down  and  pressed  firmly  against  the  woimd, 

while  the  wire  is  fastened  by  twisting  the  end  round  a  piece  of  wood;   this 

1  M.  Serre.  2  q.  Buck. 


OPERATIONS  ON  THE  TEGUMENTARY  SYSTEM.  337 


Fig.  274. 


sutui'f  mA\  reinaiu  for  six  to  ten  ilay,«,  and  if  iiminMliate  union  fail,  tiiey  still 
retain  tiie  parts  in  good  position  for  nnion  liy  granulation. 

Losses  of  inlegunieiit  fi'Oin  the  forehead  may  i)e  siipjilied  l)y  tlie 
neighboring  skin,  as  follows  (Figs.  272,  273):  The 
niai'gin  and  the  space  itself  being  well  freshened, 
dissect  up  on  either  side  flaps  which  may  be  glided 
to  such  an  extent  as  to  meet  the  flaps  on  the  oppo- 
site side  without  tension.  The  form  of  these  flaps 
must  depend  upon  the  shape  of  the  surface  to  be 
covered,  and  can  be  governed  by  no  fixed  rules. 
Restoration  of  the  lower  eye-lid  is  effected  by  the 
removal  of  a  V-shaped  flap  and  the  formation  of 
a  quadrangular  patch  from  the  cheek  (Fig.  274). 
Illustrations  of  the  methods  of  restoration  of  other 
parts,  as  the  lips,  nose,  penis,  will  be  found  in  connection  with 
those  subjects. 

10.  Cicatricial  contractions  ^  follow  all  wounds  with  extensive 
loss  of  skin,  and  as  this  is  generally  greatest  after  burns,  cicatrices 
from  this  cause  usually  contract  most;  it  results  from  the  disposition 
of  the  inflammatory  new  formation  in  the  wound  to  give  off  water  as 
the  original  gelatinous  tissue  by  degrees  atrophies  to  dry  connective 
tissue.  Operations  should  not  be  undertaken  for  the  relief  of  cicatri- 
cial contractions  until  every  proper  effort  has  been  made  to  overcome 
them ;  for  in  the  course  of  months  or  years  the  vessels  are  obliterated, 
and  the  structure  becomes  more  like  that  of  subcutaneous  tissue, 
being  less  rigid,  more  distensil)le,  tougher,  more  elastic;  hence  mo- 
bility increases  with  time.  This  atrophy  of  the  cicatrix  may  be 
aided  by  comj)ression  and  distention,  long  and  per- 
sistently applied.  When  these  measures  have  ac- 
complished all  that  can  be  reasonably  expected, 
some  one  of  the  many  methods  practiced  may  be 
adopted.  Tn  general,  the  entire  cicatrix  should,  if 
possible,  be  removed,  and  its  place  supplied  with 
new  skin.  This  may  be  effected  when  the  cicatrix 
is  narrow  and  linear  (Fig.  275),  as  follows  -.^  Dis- 
sect out  the  cicatricial  tissue  cleanly;  now  make 
incisions  on  either  side  of  the  wound,  parallel  to 
its  borders,  ami  two,  three,  or  more  inches  from 
them,  through  the  subcutaneous  tissue  ;  loosen 
these  strips  sulRciently  to  permit  of  their  accurate  Fio.  275. 

approximation;  unite  them  l)y  suture  and  allow  the  lateral  spaces 
to  heal  by  granulation  (Fig.  276).  In  many  cases  the  distorted 
parts  may  be  liberated  by  detaching  them  from  their  underlying 

1  T.  Billroth.  2  x.  D.  Mutter. 

22 


338 


OPERATIVE  SURGERY. 


Fig.  276. 


connections  sufficiently  to  allow  them  to  be  restored  to  their  nor- 
mal relations,  and  then  transplaiitini^  sound  skin 
from  the  nearest  available  locality  with  which  to 
fill  up  the  space  made  bare  l)y  the  restoration.^ 
Finally,  the  corded  folds  that  maintain  the  con- 
traction may  be  excised  and  the  edges  of  the 
wound  divided  at  every  point  where  any  resist- 
ance still  remains  which  prevents  complete  exten- 
sion of  the  part,  or  even  dissecting  up  the  edges 
from  their  underlying  connections,  the  purpose 
being  to  give  the  utmost  freedom  of  motion  ;  the 
second  step  is  by  mechanical  appliances  to  main- 
tain parts  in  their  restored  position  imtil  cicatriza- 
tion is  complete,  and  for  a  longer  period  if  neces- 
sary; the  third  factor  in  the  cure  is  to  regulate 
the  process  of  cicatrization  so  as  to  keep  a  smooth  and  even  surface, 
by  repression  of  the  granulations  with  caustics  thoroughly  applied, 
and  by  adhesive,  or  better,  rubber  plaster,  applied  firmly  and  so  as  to 
overlap  each  other;  if  contracting  bands  form  they  must  be  divided; 
cicatrization  may  be  aided  by  leaving  islets  of  cicatricial  skin  on 
the  wound  or  by  transplanting  skin  to  the  part.^ 

The  selection  of  any  one  method  must  depend  upon  the  situation  and  con- 
dition of  the  particuhir  cicatrix.  In  the  flexure  of  joints,  simple  subcutaneous 
division  of  the  bands  at  man}'  points,  combined  witii  extension  b_v  instruments, 

will  frequently  prove  successful;  where 
the  cicatrix  is  broad,  flat,  and  dense, 
transplantation  of  skin  must  be  prac- 
ticed; if  the  lip  is  destroyed,  it  may  be 
reconstructed  by  a  series  of  operations 
(p.  344,  et  seq.);  if  the  lower  eyelid  is 
injured,  the  cicatrix  may  be  replaced  by 
the  iiealthy  skin  of  the  cheek  (Fig.  274); 
if  the  lower  jaw  is  depressed  and  fixed, 
the  cicatrix  may  vary  in  extent  and 
firmness  so  much  as  to  require  a  judi- 
cious selection  of  one  or  more  methods 
in  any  individual  case.  The  following 
operation  on  a  cicatrix  of  the  neck  il- 
lustrates a  combination  of  methods:  — 

This  cicatrix  generally  consists  (Fig. 
277)  of  a  broad,  dense  structure,  extend- 
ing from  the  lower  border  of  the  under 
jaw  to  the  top  of  the  sternum  and  clavi- 
cles, and  preventing  the  elevation  of  the  jaw;  the  saliva  escapes  from  the  mouth, 
and  the  tongue  is  exposed  to  view.  Operate  as  follows  :  ^  first,  divide  the  entire 
•  cicatricial  band  into  three  serrated  angular  flaps,  by  two  diverging  incisions  car- 
ried from  the  symphisis  nienti  downward  and  outward  to  either  lateral  margin 
1  G.  Buck. 


Fig.  277. 


OPERATIONS   ON  THE   TEGUMENTARY  SYSTEM.   339 


of  the  band  where  it  joins  the  clavicles ;  from  these  terminal  points  make  in- 
cisions, one  along  either  margin  of  the  band  upwards  and  outwards  to  the  lower 
edge  of  the  jaw;  dissect  up  these  three  flaps  from  the  connective  tissue,  begin- 
ning at  their  apices,  and  proceeding  toward  and  slightly  beyond  their  bases;  the 
head  is  tlius  relieved  and  can  be  moved  in  every  direction;  readjust  the  detached 
flaps  to  the  denuded  surface  while  ilie  head  is  kept  in  an  elevated  position;  ex- 
cise redundant  folds  and  pare  oft"  tiie  edges  of  the  flaps,  if  necessary,  to  adapt 
them  to  each  other;  incision  may  lie  made  along  the  base  of  the  neck  to  relieve 
tension;  in  the  subse(|ueiit  treatment  the  chin  must  be  maintained  elevated  by 
apparatus,  as  a  stock,  or  a  chin-support  attached  to  a  spiral  brace;  if  at  any 
time  the  granulations  become  exuberant  they  are  reduced  by  apjilying  ihe  solid 
nitrate  of  silver  and  pressing  it  firmly  into  them,  or  by  the  caustic  potassa;  if 
new  cicatricial  bands  form  they  are  divided  at  two  or  more  points,  and  entirely 
through  their  thickness.  The  result  is,  in  ordinary  cases,  complete  relief  from 
the  effects  of  the  cicatrix. 

The  obliteration  of  depressed  cicatrices  after  glandular  abscesses 
and  exfoliation  of  bone  has  been  effected  by  the  following  opera- 
tion:* Subcutaneously  divide  all  of  the  deep  adhesions  of  the  cicatrix 
with  the  tenotomy  knife  introduced  a  little 
beyond  its  margin  and  carried  down  its 
base  ;  carefully  and  thoroughly  evert  the 
depressed  cicatrix,  turning  it  inside  out  so 
that  the  cicatricial  tissue  remains  perma- 
nently raised;  pass  two  hare-lip  pins,  or 
finer  needles,  through  the  base,  at  right  an- 
gles to  each  other  (Fig.  278),  so  as  to- 
maintain  the  cicatrix  in  its  everted  and 
raised  form  for  three  days;  remove  the 
needles  and  allow  the  cicatricial  tissue  to  fall  to  the  level  of  the  sur- 
rounding integument. 

Cicatrices  predispose  to  the  development  of  false  keloid  growths, 
which  belong  to  the  sarcomatous  series  ;  these  tumors  rather  replace 
a  scar,  than  grow  out  of  one;  in  the  regular  course  of  development 
of  a  scar,  the  presence  of  round-cell  and  si)indle-cell  tissue  is  only 
provisional,  as  they  speedily  give  place  to  fibroid  tissue;  but  either 
one  of  these  elements  may  persist  longer  than  its  proper  time,  and 
if  it  accumulates  in  disproportionate  amount,  a  sarcomatous  tiunor  is 
produced  instead  of  a  scar.^  They  appear  as  nodular  hypertrophies 
of  the  cicatrix,  of  a  dusky  or  liluish  color.  They  may  give  rise  to 
no  symptoms,  and  finally  disappear,  or  they  may  become  very  sensi- 
tive and  painful,  with  intolerable  itching.  No  treatment  is  required, 
unless  the  growth  is  very  troublesome.  The  most  efficient  remedies 
are  blisters;  these  may  be  followed  by  friction,  with  mercurial  oint- 
ment and  extract  of  belladonna.  If  no  relief  is  obtained,  excision  of 
the  cicatrix  must  be  performed,  to  be  repeated  if  the  growth  returns. 
1  W.  Adams.  2  E.  Rindfleisch. 


Fig.  278. 


VII. 

THE    DIGESTIVE    ORGANS. 


CHAPTER  XXX. 

THE   LIPS. 

I.    WOUNDS. 

The  lips  are  covered  externally  by  skin,  internally  by  mucous 
membrane,  and  contain  fat,  glands,  and  muscle. 

1.  'Wounds  of  the  lips  gape  widely,  and  can  be  retained  in  per- 
fect apposition  only  by  suture.  If  tbe  wound  is  partial,  the  silk  or 
wire  suture,  with  adhesive  strip,  will  suffice;  but  if  the  entire  lip  is 
divided  the  hare-lip  pin  should  be  used  (Fig. 
279).  If  there  is  haemorrhage,  a])ply  torsion  to 
the  artery,  or  pass  the  suture-pin  through  it;  re- 
move the  suture  on  the  third  or  fourth  day. 


II.  CONGENITAL  DEFECTS. 
Hare-lip  is  a  congenital  non-union  of  the  cen- 
tral, or  of  the  central  with  the  lateral  portion  of 
the  upper  lip,  the  cleft  corresponding  with  the  junction  of  the  in- 
termaxillary, or  of  the  maxillary  and  intermaxillary  bones;  ^  it  is 
most  common  in  males  and  is  frecjuently  hereditary;  ^  it  may  be 
single,   double,  or  complicated. 

The  fissure  3  may  appear  as  a  short  notch,  but  in  general  it  extends  to  within 
a  little  of  the  nostril,  and  is  often  continuous  with  it;  when  double  it  may  be 
of  the  same  size  on  each  side,  or  there  may  be  a  short  notch  on  one  side  and  an 
extensive  one  on  the  other;  the  substance  of  the  lip  always  varies  much  in  such 
cases,  being  thick  and  fleshy  in  some  and  in  others  thin  and  defective  in  all  re- 
spects, and  the  breadth  of  the  gap  usually  varies  in  accordance  with  these  char- 
acters. There  is  always,  even  in  the  worst  cases  of  double  cleft,  an  interme- 
diate portion  of  lip  which  may  be  broad  or  narrow,  long  or  short,  thin  or  of  the 
natural  thickness  of  the  lip,  but  generally  it  is  deficient. 

1  W.  Froelik.  2  c  Forster.  ^  Sir  W.  Fergusson. 


THE  LIPS. 


341 


;  (3) 

281) 


The  general  rules  of  treatment  are:  (1)  If  the  infant  is  feeble, 
delay  operation  until  after  the  third  month  ;  (2)  if  healthy,  and  the 
cleft  single,  operate,  if  it  is  desire<l,  immediately;^  if  there  is  no 
speeial  urgeney,  delay  till  from  the  third  month  to  the  ;^i.xth  month  ;  ^ 
the  comparative  mortality  in  the  different  periods  favors  the  latter 
course;*  (3)  when  there  is  inability  to  fake  food,  operate  at  the 
earliest  moment ;  (4)  defer  the  operation,  if  diarrhcca  or  eruptive 
diseases  are  present  during  first  dentition,  and  in 
midsummer  months ;  *  (5)  if  the  hare-lip  is  double, 
wait  until  the  child  is  two  or  three  years  old,'^ 
unless  the  conditions  render  an  earlier  operation 
necessary;  (0)  chloroform  is  not  necessary  in  infants. 
The  stages  of  the  operation  are  :  (1)  the  infant,  hav- 
ing a  sheet  wrapped  around  its  body  so  as  to  in-  /^ 
close  its  arms,  should  be  held  upright  in  the  arms  of  ('  /^^ 
an  experienced  assistant,  and  ils  head  firmly  grasped  ^v>-<' 
by  a  second  assistant  (Fig.  280)  ;  the  older  child  should  j,-,^^,  .28o. 
recline  with  its  head  raised;  (2)  separate  thoroughly 
all  adhesions  to  the  gums  so  that  the  two  flaps  move  freely 
make  section  of  the  edges  of  the  cleft  with  strong  scissors  (Fig. 
or  with  the  knife  (Fig.  282),  and  in 
such  form  as  will  most  completely  oblit- 
erate deformity  when  the  flaps  are 
placed  in  perfect  apposition;  (4)  close 
the  wound  with  hare-lip  pins  if  the 
tension  is  great  (Fig.  283),  and  with  silver  wire  su-  Fio.  282. 

ture  if  it  is  but  slight ;  introduce  the  suture  so  deeply  as  to  reach, 
but  not  to  penetrate,  the  mucous  membrane:   (5)   support    (\ 
the  flaps  with  long  adhesive  strips,  or  with  a  well-adapted 
truss  (Fig.  284).  -^ 

1.  Single    hare-lip   may  occin-   on   either  side  and  mny  I'ifi- 283. 
vary  in    extent    from    a    slight   indentation   to  a  complete   division 
into  the  nostril.     The  two  sides  of  the  cleft  differ 
in  their  regularity,  being  on  different  levels,  and 
variously  beveled  at  the  angles.      If  the  knife  is 
use<l,  enter  it  at  the  angle  and  cut  away 
a  sufficient  portion   to  make  the  margin     v4t;^ 
straight,  and  secure  easy  and  perfect  ad-  jjr^i  J 
justment;  at  the   free  border  (Fig.  28^)       """^  _ 
turn    the  edge   inward   to  the   cleft  and     '*^'  "  ^' 
save  a  portion  of  the  mucous  membrane  to  avoid  the  notch  in  the 
lip.     If  the  scissors  are  preferred,  the  same  section  can  be   made. 
If  the  free  borders  are  irregular  and  round,  the  method  of  saving 
1  SirW.  Fcrgusson.         2  S.  D.  Gross.         s  T.  Bryant.        *  F.  H.  Hamilton. 


Fig.  281. 


Fig.  284. 


342 


OPERATIVE  SURGERY. 


t.s 


Fig.  286. 


Fig.  287. 


Fig.  288. 


the  parings  ^    should   be  adopted,  namely,   make  an  incision  from 
1  to  2  (Fig.  28G),  through  the  thickness  of  the  lip  to  the  free  margin, 
which  should  not  be  divided;  on  the  other  side  transfix  the  lip  at 
/  3  and  separate  a  flap  as  far  as  4,  dividing 

/A      k  it  at  5  ;  bring  the  two  sides  together  and 

V^IA^L         attach  the  flap  5,  3,  to  1,  by  a  suture,  and 
the  flap,  5,  4,  to   2;  apply  two  interme- 
diate sutures,  and  the  result  will  be  a  lip 
nearly  double  in  depth  of  that  obtained  by 
the  ordinary  method  (Fig.  287);  the   same  result  follows  if  the  two 
portions,  pared   off  the  sides  of  the  cleft,  remain 
attached  to  each  other  (Fig.  288),  as  well  as  to  the 
free  edge  of  the   lip,    and  are  turned  downwards 
and  the  two   sides   are   united   as   before. ^      This 
method  is   peculiarly  appropriate  to  clefts  which 
do  not  extend   through    the   whole    depth   of   the 
lip,    but    terminate    at    some    distance   from    the 
nostril.3 

In  cases  of  very  extensive  cleft,  or  witli  a  projection  of  one  portion 
of  the  jaw,  the  following  operation  is  ad- 
vised :  ^  Cut  flaps  on  either  side  (Fig. 
289)  and  leave  them  attached,  on  one  by 
the  lower,  and  on  the  other  by  the  upper 
end,  the  incision  being  carried  around  the 
nose  as  far  may  be  deemed  necessary ;  the 
flap  attached  by  its  lower  end  is  then  turned  downwards  so  that  its 
red  edge  forms  the  border  of  the  lip,  while  the  other  is  drawn  up- 
wards towards  the  nostril,  and  they  are  thus  dovetailed  together 
(Fig.  290)  with  interrupted  sutures.* 

In  some  cases  the  continuity  of  the  lip  border  may  best  be  pre- 
served by  the  following  method  :  ^  Remove  the  edge  of  one  of  the 
borders  clearly  throughout;  on  the  other  cut  a  flap  (Fig.  291)  with 
its  pedicle  below;  bring  the  edges 
together  so  that  the  flap  is  applied 
from  below  upwards  upon  the  notch. 
If    the   flaps   in    any    case    do   not 
Fig.  291.  promptly  unite  and  the  edges  con- 

tinue to  granulate,  they  should  be  maintained  in  apposition  for  the 
purpose  of  securing  union  by  granulation.® 

2.  Double  hare-lip  may  exist  with  or  witbout  defect  in  the  bone. 
When  complicated  with  fissure  of  the  hard  palate,  the  best  conducted 
operations  are  very  liable   to  fail.''     If  the  clefts  are  limited  to  the 


Fig.  290. 


Fig.  292. 


1  M.  H.  Col 

*  Giraldt'S. 


2  M.  Clemot;  J.  F.  Malgaij.me. 
5  Mirault.  6  Sir  J.  Payet. 


3  T.  Holmes. 
■?  M.  GuersaiU. 


THE  LIPS. 


343 


Fig.  2!i3. 


lips  (Fig.  293),  and  there  is  not  severe  tension,  operate  upon  both 
sides  at  the  same  time  (Fig.  294);  but 
if  the  traction  upon  the  parts  is  great, 
operate  upon  one  side  at  a  tiuie,  mak- 
ing a  central  flap  which  can  be  attached 
at  the  sides  and  to  the  angles  of  the 
flaps  (Fig.  294). 

If  the  internia.xillary  bone  has  not  formed  ossific  union,  it  jirujects 
more  or  less,  according  to  its  attachments  to  the  septum  nasi.  Ex- 
cept when  it  is  a  mere  pendulous  mass  from  the  tip  of  the  nose, 
efforts  should  be  made  to  save  it,  both  because  it  contains  the  sacs  of 
the  incisor  teeth,  and  its  presence  is  necessary  to  maintain  the  form 
of  the  upper  jaw  and  lip.^  In  the  slighter  cases  of  projection  of  the 
intermaxillary  bone  it  is  merely  necessary  to  fracture  its  attachment 
to  the  septum,  and  press  the  mass  back  into  position,  or  if  it  be  too 
large  to  fit  the  gap,  the  exuberant  parts  must  be  pared  away  at  the 
sides,  the  adjacent  sides  of  the  superior  maxillary  bones  refreshed, 
and  any  teeth  projecting  across  the  cleft  removed.^ 

A  wedge-shaped  piece  may  be  cut  from  the  septum, ^  which  allows 
the  mass  to  recede  more  readily  into  the  cleft  (Fig.  29.0);  a  suture 
may  be  applied  to  the  sides  of  this  notch  to  retain  the 
depressed  bone  in  place. ^  The  bone  has  been  re- 
tained in  position  by  silver  sutures  passed  through  it 
and  the  adjoining  hard  palate,*  but  three  teeth  were 
destroyed  by  the  penetration  of  their 
sacs.  The  bone  has  been  successfully 
held  in  position  by  at  once  uniting  the 
clefts  in  the  soft  tissues.^  When  the 
flaps  are  insufficient  to  close  the  cleft, 
they  may  be  dissected  away  from  the  cheek  to  such 
,^^r  f  an  extent  as  to  admit  of  their  easy  approxi- 
^•■"X  mation.  If  the  process  is  tedious  it  should 
be  divided  into  stages,  dealing  first  with  the 
projecting  intermaxillary  bone,  and  then 
with  the  soft  [)arts.i  ^Vhen  the  mass  is  sus- 
pended from  the  tip  of  the  nose  (Fig.  296), 
Fig.  296.  it  must  be  removed  by  careful  dissection  with  stronor  scis- 
sors, the  soft  parts  being  retained  and  so  placed  as  to  form  a  col- 
umna  nasi,  or  to  fill  the  gap  in  the  lip  (Fig.  297). 


Fig.  295. 


Fig.  2'jr. 


III.     HYPERTROPHY. 
Hypertrophy  of  the  mucous   glands  is  characterized  by  two 
elevated  pendulous  portions  of  tissue  appearing  on  either  side  of  the 
1  T.  HohiK'S.  -  G.  lilandiu.  3  liruiis.  •*  Vou  Laiisreubeck. 


344 


OPERATIVE  SURGERY. 


middle  line  (Fig.  298),  and  is  due  to  an  increase  of  the  glands  of  the 
part  and  not  of  the  mucous  membrane.  Make  a  straight  or  elliptical 
incision  in  the  line  of  the  lip;  excise  the  submu- 
cous tissue;  close  the  incision  with  tine  sutures.^ 
2.  Hypertrophy  of  the  lip  generally  occurs 
in  scrofulous  subjects,  and  consists  in  chronic 
thickening  of  the  deep  structures.  It  may  result 
from  a  congenital  enlargement  of  the  capillaries 
constituting  a  nasvus  (Fig.  299).-  and  then  has 
a  raspberry  discoloration,  is  tlal)by,  pendulous, 
and  contains  hard  knots  in  its  substance.  Op- 
erate as  follows:  2  Remove  a  V-shaped  patch, 
equidistant  from  the  angles  of  the  mouth,  and 
havin"  its  apex  low  down  in  the  median  line 
under  the  chin;  divide  the  mucous  membrane 
along  the  line  of  its  reflection  from  the  jaw 
on  either  side  of  the  wound;  bring  the  opposite 
edges  of  the  wound  together  and  secure  them 
in  exact  co-aptation  by  pin-sutures  inserted  at 
equal  distances  from  each  other  below  the  lip- 
border;  between  every  two  pin-sutures  add  a  sil- 
ver wire,  and  on  the  vermilion  border,  fine  thread 
sutures,  one  being  on  its  buccal  surface;  when 
union  is  complete,  a  second  operation  is  required 
to  reduce  the  thickness  of  the  lip.  This  is  effected  by  two  parallel 
incisions,  including  one  third  of  the  thickness  of  the  lip  and  pene- 
trating deeply  into  its  substance;  the  resulting  wound,  well  secured, 
rapidly  heals  and  reduces  the  lip  to  the  normal  size.  The  rasp- 
berry color  must  be  destroyed  by  the  actual  cautery. 

IV.    ACQUIRED    DEFECTS. 

1.  Reconstruction  of  the  lips  after  losses  from  injuries  or  dis- 
eases has  now  been  reduced  to  very  exact  methods,  and  the  results 
which  have  been  obtained  are  in  the  highest  degree  creditable  to 
the  author.2  The  following  examples  illustrate  the  principles  Avhich 
should  guide  in  planning  and  executing  these  perplexing  operations, 
and  the  details  of  their  performance  :  — 

1.  The  lower  lip^  is  reconstructed  as  follows :  first  remove  the  diseased  por- 
tion. This  may  be  done  by  the  V-shaped  or  quadrilateral  flap.  The  V-shaped 
flap  is  made  as  follows :  make  an  incision  commencing  at  a  point  within  half  an 
inch  of  the  angle  of  the  mouth  on  both  sides,  and  dividing  the  lip  border,  carried 
downward  on  eitiier  side  of  the  morbid  growth  in  converging  lines,  till  both  in- 
cisions meet  under  the  chin  in  the  median  plane;  this  flap  should  be  dissected 
up  from  the  i)eriosteum  and  removed;  next  divide  the  lining  mucous  membrane 
1  T.  Bryant.  ^  q.  Buck. 


THE  LIPS. 


345 


of  the  mouth  on  both  5ides  of  the  wound,  alonp  the  line  of  its  reflection  from  the 
jaw  to  the  inside  of  tlie  lip,  and  continue  it  outward  as  far  as  is  necessary  to 
permit  the  ed<;cs  of  the  V-shaped 
wound  to  meet  at  the  symphisis 
and  be  secured  by  sutures.  After 
the  parts  have  healed,  the  mouth 
is  restored  by  the  foliowinj'  op- 
eration ( Kij;;.  300):  first  designate 
the  incisions  by  points,  as  at  a, 
b,  and  c,  b  ;  then  with  the  fore- 
finger of  the  left  hand  placed  on 
the  inside  of  the  mouth,  transti.K 
the  lip  at  a,  on  the  rij,dit  side  and 
carry  an  incision  through  the  en- 
tire cheek  upwards  and  outwards 
an  inch  and  a  half  to  b,  near  the 
middle  of  the  dieek ;  next  trans- 
fix tlie  lip  at  c,  and  carry  the  incis- 
ion outward  to  join  b;  then  make 
an  incision  from  the  starting  point  n,  vertically  downward  to  the  c-dge  of  the 
jaw  </,  and  to  the  periosteum;  by  retracting  this  incision  a  V-shaped  space  is 

ma<le  for  the  lodgment  of  the  trian- 
gular flap,  (I,  b,  c,  and  a  new  and 
naturally-shaped  angle  is  formed  for 
the  mouth  at  the  point  c;  the  same 
procedure  is  required  en  the  opposite 
side  (Fig.  300)  at  the  same  or  a  sub- 
sequent sitting;  the  result  (Fig.  301) 
is  a  newly-formed  mouth  with  good 
angles. 

The  quadrilateral  flap  is  made  when 
a  large  section  is  removed  (  Fig.  .302).! 
Make  incisions,  a  to  b,  commencing  at  a  point  within  less  than  half  an  inch  of 
each  angle  of  the  mouth,  verti- 
cally downwards  till  they  join 
a  transverse  incision  b,  b,  cross- 
ing the  lower  part  of  the  chin  ; 
dissect  this  flap  from  the  perios- 
teum; now  continue  the   trans-  

verse  incision  outwards  on  both  f^ l^  —  Xi- •      C 

cheeks  to  a  point  within  a  fingers' 
breadth  of  the  angles  of  the  jaw 

and  thence  upwards  a  distance  of iV"  f^ff^g^fc^  ■  CI 

of  two  inches  in  a  line  curving 
slightly  forwards.  6  c  and  b  c  ; 
dissect  up  these  cheek  flaps  on 
both  sides,  and  divide  the  mu- 
cous membrane  alone,  along  tliel,,..-- 
anterior  margin  of  the  masseter 
muscle  upwards,  and  thence  for- 
wards to  the  upper  canine  teeth;  yiQ  gyo. 
the  two  cheek  flaps  thus  formed 

1  G.  Buck. 


346 


OPERATIVE  SURGERY. 


must  be  glided  forwards  edgewise  towards  each  other  and  made  to  meet  over 
the  symphisis  menti,  where  they  are  secured  in  accurate  coaptation  b}'  three 
pin-sutures  and  intermediate  fine  thread  sutures;  close  the  spaces  left  bare  by 
approximating  the  apposite  edges  and  securing  them  by  sutures;  the  facial  arte- 
ries are  necessarily  cut  and  must  be  promptly  ligated.  The  result  of  this  opera- 
tion is  a  circular  and  pouting  shape  of  the  mouth  (Fig.  300).  A  second  opera- 
tion is  required  to  remedy  this  defect:  Make  an  incision  on  each  side,  through 
the  cheek  from  a  to  6,  another  from  c  to  b,  and  a  third  vertically  from  a  to  d,  as 
already  described  (Fig.  300),  and  adjust  the  flaps  as  directed.  The  result  of  the 
la>t  operation  is  a  well-formed  mouth. 
•2.  The  lower  lip  destroyed  by  a  shell  wound  was  restored  as  follows^ 
(Fig.  303):  Two  incisions  were  made  dividing 
the  under  lip,  one  from  d,  and  the  other  from  b, 
converging  to  c,  under  the  chin;  this  V-shaped 
flap  was  removed,  including  a  notch  upon  the 
lip  border,  and  the  adherent  portion;  the  re- 
maining left  half  of  the  lip  and  the  adjacent 
cheek  were  detached  from  the  jaw  as  low  down 
as  its  inferior  border,  and  as  far  back  as  the 
last  molar  tooth;  this  dissection  permitted  the 
parts  to  glide  towards  the  right  side  and  in  part 
fill  the  chasm  left  by  the  removal  of  the  V-flap. 
Fig.  303.  The  next  step  was  to  make  a  quadrilateral  flap 

by  the  incisions  d  to  (i,  and  a  to  e,  which  was  glided  forward  edgewise  till 
it  met  the  left  half  of  the  under  lip  to  which  it  was  attached;  new  lip  border 
was  constructed  on  the  upper  edge  of  the  transferred  cheek-patch  by  excising  a 
prism-shaped  strip  of  tissue  from  between  the  skin  and  mucous  membrane.  The 
mouth  was  also  lengthened  on  the  right  side,  and  a  border  made  as  just  described ; 
a  new  angle  was  also  made  b^'  securing  the  opposite  edges  of  the  divided  cheek 
together  at  a  point  where  the  newlv  constructed  upper  and  lower  lip  borders  ter- 
minated; the  space  in  the  right  cheek  was  filled  by  extending  the  tranverse  in- 
cision, loosening  the  skin  and  gliding  it  forward.  At  a  second  operation  the  left 
angle  of  the  mouth  was  extended  by  the  method  given  (Fig.  300),  and  the  result 
was  satisfactorv  (Fig.  301). 


Fig.  304.  Fig.  305. 

3.  The  lower  lip  and  chin  destroyed  by  gunshot  (Fig.  304)  have   been 
reconstructed  hv  a  similar  operation.'^    The  lower  jaw  was  carried  awav  from 
1  G.  Buck.  2  J.  vv.  S.  Gouley. 


THE  UPS. 


347 


the  secontl  bicuspid  toolh  on  the  left,  to  the  second  molar  tooth  on  the  right. 
The  incisions,  commencing  at  the  margin  of  the  cicatrix,  in  the  cleft  of  the  lip, 
extended  on  eitlier  side  to  the  angles  of  the  jaw,  and  tiience  upwards  to  c  (Fig. 
302)  until  both  flaps  became,  on  loosening  their  deep  attachments,  so  free  as  to 
meet  readily  in  the  median  line.     .V  useful  lip  resulted  (Fig.  305). 

4.  The  right  half  of  both  lips  was  restored  as  follows:  i  The  right  cheek 
was  detached  from  the  jaws  above  and  below,  and  the  dissection  continued 
in  every  direction  till  the  jaws  could  be  separated  far  enough  to  admit  the 
thumb  edgewise  between  the  front  teeth;  the  thinned  cicatricial  edge  of  the 
right  cheek,  bordering  on  the  region  of  the  angle  of  the  month,  was  pared 
afresh  for  adjustment  to  the  new  lip;  both  lips  were  now  deiaciied  from  their 
connections,  the  upper  by  an  incision  from  the  ala  nasi  to  the  middle  of  the  left 
cheek;  the  lower  by  an  incision  across  the  middle  of  the  chin  parallel  with  and 
as  far  into  the  left  cheek  as  the  former;  this  bifurcated  quadrilateral  flap  was 
advanced  towards  the  right  side  of  the  face,  and  its  two  extremities  adjusted 
with  the  lip  bordei-s  in  contact  with  each  other,  by  pin  and  thread  sutures; 
the  result  was  a  contracted  mouth  drawn  to  the  right  side.  This  defect  was 
remedied  as  previously  described  (Fig.  300),  and  the  mouth  assumed  sym- 
metrical proportions. 

5.  The  upper  lip  and  adjacent  portion  of  the  cheek  may  be  recon- 
structed by  material  taken  from  the 
under  lip  i"  (Fig.  30G),  as  follows:  (1.) 
Divide  the  extremity  of  the  upper  lip 
where  it  joins  the  right  cheek,  through 
its  entire  thickness,  at  right  angles  to 
its  border,  to  the  extent  of  one  inch 
from  the  border,  a  to  6;  make  a  sec- 
ond incision  from  b  to  c,  one  and  a 
half  inches  long,  parallel  to  the  bor- 
der of  the  lip;  fold  this  quadrilateral 
flap  edgewise  upon  itself  and  to  en- 
able it  to  meet,  and  be  adjusted  to, 

the  remaining  half  of   the  upper  lip:  . 

divide  its  base  obliquely  half  across, 

c  to  <f ;  liberate  the  left  half  of  the  upper  lip  by  incising  the  buccal  mucous 
membrane  along  the  line  of  its  reflection  from  the  jaw  to  the  lip  and  cheek,  and 

detaching  the  parts  towards  the  orbit 
from  the  underlying  periosteum  on  the 
right  side;  pare  a  strip  of  vermilion 
border  from  the  extremity  of  the  half 
lip  of  such  length  as  will  permit  it  to 
be  matched  to  the  free  extremity  of  the 
under-lip  flap;  unite  the  two  flaps  in  a 
vertical  line  by  sutures,  and  close  the 
space  between  the  newly-adjusted  half 
of  the  month  and  the  neighboring  cheek 
by  approximating  the  opposite  parts. 
The  result,  when  the  healing  is  com- 
plete, is  a  circular  and  pouting  mouth. 
(Fig.  307.) 
6.  The  angle  of  the  lips  is  re- 
Make  an  incision  along  the  line  of  the  vermilion 

I  G.  Buck. 


Fig.  307. 
stored,  as  follows  i  (Fig.  307) 


348 


OPERATIVE  SURGERY. 


border,  circumscribing  the  circular  half  of  the  mouth  and  extending  to  an  equal 
distance  on  the  upper  and  lower  lips,  a  to  6,  dividing  only  the  skin;  now  insert 
a  double-edged  knife  at  the  middle  of  this  curved  incision  and  direct  it  flat- 
wise towards  the  cheek  between  the  skin  and  mucous  membrane,  so  as  to 
separate  them  from  each  other  as  far  as  the  new  angle  of  the  mouth  is  to  be 
extended;  divide  the  skin  with  strong  scissors  on  a  line  with  the  commissure 
of  the  mouth  outwards  towards  the  cheek,  d  to  c;  now  divide  the  mucous  mem- 
brane on  tiie  same  line,  but  not  so  far  outward  as  the  incision  of  the  skin,  and 
attach  the  angle  at  the  terminus  of  the  incision  of  the  mucous  membrane  to 
the  corresponding  angie  of  the  skin  by  a  single  thread  suture;  the  fresh-cut 
edges  of  skin  and  mucous  membrane  above  and  below  that  are  to  form  the  new 
lip  borders  are  to  be  shaped  bj'  paring  so  that  the  mucous  membrane  shall  over- 
lap the  skin  after  they  have  been  secured  by  fine-thread  sutures  inserted  close 
together. 

7.    The  right   half  of  the  upper  lip  is  reconstructed  thus:  after  the  loss 

of  portions  of  the  cheek,  the 
ala  nasi,  and  the  entire  su- 
perior maxilla  (Fig.  308)  ; 
prepare  the  left  half  of  the 
upper  lip  by  incising  the 
buccal  mucous  membrane 
along  the  line  of  its  reflec- 
tion from  the  upper  jaw  to 
the  lip  and  cheek  as  far  as 
the  molar  teeth;  next  divide 
the  lip  through  its  entire 
thickness  from  the  point 
where  it  joins  the  ala  nasi, 
on  a  line  parallel  with  the 
lip  border  outwards  to  the  middle  of  the  cheek,  a  to  b,  and  trim  it  square  at  its 
free  extremity;  prepare  the  redundant  under  lip  so  as  to  employ  it  for  supply- 
ing the  deficient  rigiit  half  of  the  upper  lip  according  to  the  method  described  in 
I'ig.  30(1,  namely,  by  incisions  from  c  to  d.  d  to  e,  and  e  to  y  below  (Fig.  308) ; 

the  open  space  in  the  right  cheek 
resulting  from  the  transposition  of 
the  parts  is  closed  by  making  a 
transverse  incision  through  the  en- 
tire cheek  on  a  line  with  the  com- 
missure of  the  mouth  as  far  out- 
ward as  the  masseter  muscle,  and 
beyond  it  only  through  the  skin; 
by  dividing  the  buccal  mucous 
membrane  along  the  anterior  edge 
of  the  masseter,  above  and  below, 
the  cheek  may  be  brought  forward 
and  united  to  the  under  lip  flap. 
The  result  of  this  operation  (Fig. 
309)  required  next  the  restoration  of  the  right  half  of  the  mouth;  this  was 
effected  by  the  incisions  outlined,  and  as  described  in  the  reconstruction  of  the 
mouth  (Fig.  307).  Closure  of  the  opening  in  the  nose  was  effected  by  another 
operation. 

1  G.  Buck. 


Fig.  J08. 


Fig.  309. 


THE  LIPS. 


349 


a 


e 


I'lG.  :Jlu. 


8.  The  upper  lip  and  nose  is  restored  thus  i  (Fig.  310):  An  incision  throu^jh 
the  cheeks  and  lip,  cinnincncii);;  at  ihi-  median  line,  on  a  level  with  the  floor  of 
the  nasal  cavity,  was  carried  mn^^^KK  '^ 

outward  and  downward  on  " 

both  sides  of  the  face  in  a 
curved  line  so  as  to  circum- 
scribe both  angles  of  the 
mouth,  aii'l  terminate  at  a 
point  below  the  junction  of 
the  middle  and  outer  third 
of  the  under  lip,  a  to  h,  a  to 
c ;  those  flaps  were  brought 
toward  each  other  edgewise, 
and  their  ends  being  pared 
and  made  straight,  were  ad- 
justed to  each  other  on  a 
vertical  line  in  tlie  median  plane,  and  secured  by  three  pin  sutures  and  interme- 
diate thread  sutures;  the  open  space  was  closed  by  detaching  the  mucous  mem- 
brane from  the  cheeks,  wliich  so  far  liberated  it  that  the  cheeks  could  be  readily 

brought  forward  and  attached  to  the 
flaps  by  pin  and  thread  sutures.  The 
parts  healed,  except  at  the  point  of 
union  of  the  flaps,  where  sloughing  oc- 
curred. 

The  second  operation  was  designed 
to  remove  the  obstruction  of  the  nos- 
trils by  a  vertical  incision  from  a  point 
midway  between  the  eyebrows  down- 
ward upon  the  nose  to  a  point  on  a  level 
with  the  floor  of  the  nasal  cavity,  from 
which  a  transverse  incision  was  made, 
Iif'-  •'''•  one  inch  on  either  side;  the  flaps  were 

dissected  up,  the  parts  blocking  up  the  nostrils  were  cleared  away,  the  skin 
parted  to  correspond  to  the  bony  margin  of  the  new  opening,  and  left  to  cica- 
trize, which  followed  in  due  time.  A  third  operation  to  improve  the  upper  lip 
was  performed  nearlj'  the  same  as  the 
first,  namely,  incisions  on  each  side  of 
the  mouth,  completely  through  the 
cheek,  were  made  from  a  point  about 
half  a  finger's  breadth  below  the  nasal 
orifice,  to  corresponding  points  on  each 
side  of  the  chin,  and  at  a  distance  of 
an  inch  from  the  angles  of  the  mouth, 
and  the  border  of  the  under  lip;  these 
flaps  were  brought  together  in  the 
median  line,  and,  their  ends  being 
squared,  they  were  adjusted  by  suture 
and  the  gap  closed  as  before.  The 
results  (Fig.  311)  were  satisfactory. 
The  fourth  operation  was  designed  to 

extend  the  angles  of  the  mouth,  and  the  operation  was  in  detail  as  that  given 
(Fig.  309).  A  fifth  and  si.xth  operation  were  performed  to  reconstruct  the  nose, 
the  llap  being  cut  from  the  forehead  according  to  a  pattern  carefully  prepared, 


350 


OPERATIVE  SURGERY. 


C  — 


Fig.  313. 


and  turned  down  to  its  position.     The  final  result  of  the  several  operations  was 
entirely  satisfactory  (Fig.  312). 

9.  The  lips  and  the  nose,  after  the  loss  of  the  right  half  of  the  upper 
lip,  the  adjacent  portion  of  the  cheek,  and  right  ala  nasi,  was  restored  as  fol- 
lows (Fig.  313)  :i  The  left 
half  of  the  upper  lip,  be- 
ing held  upon  the  stretch, 
was  detached  from  the  jaw 
by  an  incision  of  the  buc- 
cal mucous  membrane,  car- 
ried along  the  line  of  its  re- 
flection from  the  jaw  to  the 
lip  and  cheek,  and  extended 
outwards  as  far  as  the  mo- 
lar teeth,  and  upward  on 
the  level  of  the  periosteum 
towards  the  orbit,  thus  en- 
abling the  lip  and  cheek  to  be  glided  over  to  the  right  side;  a  strip  of  the  ver- 
milion border,  an  inch  in  length,  was  pared  away  from  the  extremity  of  the 
half  lip  and  left  attached  temporarily;  material  for  the  dericient  half  of  the  up- 
per lip  was  obtained  from  the  redundant  right  half  of  the  under  lip  by  the 
incision  «,  b,  c,  and  according  to  the  method  given  (Fig.  306);  this  quadrilateral 
flap  was  adjusted  by  its  free  extremity  when  brought  around  edgewise  to  the 
left  half  of  the  upper  lip;  the  open  space  remaining  in  the  cheek  was  closed 
by  making  another  quadrilateral  flap,  b,  e,  f,  (j,  which  was  slid  forwards  edge- 
wise and  attached  to  the  transposed  under  lip  flap;  to  cover  the  bare  surface 
remaining,  the  incision,  e,  f,  was  prolonged  to  h,  and  the  angle,  h,  f,  y,  was 
dissected  up  and  drawn  forwards,  and  adjusted  with  sutures. 

9.  The  central  portion  of  the  upper  lip  may  be  reconstructed 
by  the  following  operation  :2  make  two  incisions,  one  on  either  side 
of  the  alfe  nasi  (Fig.  314),  down  to  the 
centre  of  the  lip,  and  then  carry  the 
united  incisions  vertically  through  the 
remaining  part  of  the  lip ;  dissect  up 
these  flaps  from  their  lateral  attach- 
ments until  they  move  freely,  and  can 
be  approximated  readily  in  the  median  line,  where  they  are  united 
by  pin  sutures,  the  wire  suture  being  used  for  the  other  edges. 


Fig.  314. 


Fig.  315. 


CHAPTER    XXXI. 

THE   PALATE. 


The  roof  of  the  mouth  consists  of  two  portions,  viz.,  the  fore  part, 
or  hard,  and  the  back  part,  or  soft,  palate;  the  former  is  covered  by 
the  periosteum  and  mucous  membrane,  which  adhere  intimately  to- 
1  G.  Buck.  2  Dieffenbach. 


THE  PALATE. 


351 


getliei"  ;  die  soft  palate  consti- 
tutes  an  incompk'te  and  niov- 
able     partUion     between     the  ^^^^gg^ 
mouth  and  i)harynx,  continued  "^^ 

from   the   posterior   border   of   ^  ^x^^^=^ 

the  hard  palate  oljliquely  down- 
ward and  backwards  ;  it  in- 
closes muscular  fibres  and  nu- 
merous glands.  1 

The  instruments  required  for  op- 
erations on  the  hard  and  soft  pal- 
ate are  as  follows  (l'"if,'.  31G) :  double- 
edged  staphyloraphy  knife,  a  ; 
seizing  forceps,  b ;  adjuster  for  wire 
sutures,  c;-  leiiacuhini  for  pulling  f^T^ 
tiie  velum  aside,  or  holding  the 
edges  of  the  flaps,  d  ;  spiral  needles 
for  sutures,  e  ;  ^  curved  scissors  for 
dividing  the  muscles,  / ;  knives 
for  paring  the  edges,  </  ,-3  perioste- 
otome, /;,■'  or/;^  wire-twisting  for- 
ceps, t;''^  an  oral  saw,  i-;o  mouth 
gag  (Fig.  3I7).3 

Fig.  316. 


^ 


==i;i 


I.    CONGENITAL  DEFECTS. 

Fissure  or  cleft  of  the  palate,  as  a  congenital  defect,  may  involve: 

(1)  only  the  uvnla,  1 
(Fig.  318);  (2)  the  soft 
palate  2  (Fig.  318);  (3) 
the  hard  palate  as  far 
forwards  as  the  middle 
of  the  palate  process  of 
the  superior  ina.xillae  or 
through  the  palate  bones 
only  (Fig.  319);  (4)  the 
alveolar  ridge  entire 
•with  the  cleft  of  the 
palate  (Fig.  320);  (5) 
cleft  or  notch  of  the  al- 
veolar ridge  with  entire  cleft  of  palate;  (6)  double  cleft  of  the  alve- 
olar ridge,  with  a  fissure  from  each  running  backwards  and  inwards 
and  joinin<j:  lichind  the  interma.xillary  bone,  becoming  continuous 
with  a  median  fissure. 


Fig.  317. 


1  Quain's  Anatomy. 
*  L.  A.  Savre. 


2  J.  M.  Sims. 

6  D.  H.  Goodwillie. 


8  W.  K.  Whitehead. 


352 


OPERATIVE  SURGERY. 


There  are  also  manj'  grades  of  separation  of  the  fissure.  Usually  the  cleft  in 
the  palate  is  narrower  in  front  and  widens  towards  the  velum,  but  in  some  the 
gap  will  be  very  wide  and  in  others  very  narrow,  though  complete  from  alveolus 
to  uvula.  In  partial  clefts  the  breadth  is  often  much  greater  than  is  apparent 
from  its  extent,  in  some  instances  giving  the  greatest  breadth  met  with.i 


Fig.  318. 


Fig.  319. 


Fig.  320. 


The  operations  undertaken  for  the  relief  of  fissured  palate  are 
staphyloraphy,  and  uranoplasty,  the  former  being  an  operation  on 
the  soft,  and  the  latter  on  the  hard  palate. 

If  the  uvula  alone  is  bifid  and  the  voice  un- 
affected, it  is  better  not  to  interfere  with  the 
fissure.  As  the  articulntion,  however,  is  gen- 
ally  affected,  closure  by  suture  is  the  rule  of 
treatment  ;^  the  operation  may  be  performed 
at  any  age,  but  it  is  better  to  defer  it  until 
the  child  is  at  least  three  or  four  years  old,^ 
or  even  until  adult  life,^  when  circumstances 
are  unfavorable  to  an  early  operation.  If 
the  patient  is  a  child,  chloroform  should  be 
criven  and  the  gag  inserted  /  (Fig.  321).^ 
1.  Staphyloraphy,  suture  of  the  soft  palate,  is  an  operation  which 
the  surgeon  need  have  no  hesitation  of  undertaking  when  the  cleft  is 
limited.!  Place  the  patient  in  a  chair  in  a  good  light,  first  seize  one 
point  of  the  cleft  with  long  spring  forceps,  draw  it  forwards,  trans- 
fix it  near  its  inner  border  with  a  narrow,  sharp  knife  on  a  long 
handle,  and  freely  cut  upwards  or  downwards  and  remove  the  mu- 
cous membrane  along  the  whole  of  its  inner  margin  (Fig.  322);  make 
the  same  section  on  the  opposite  side  and  insert  two  sutures. ^ 

When  the  cleft  extends  forwards  through  the  whole  of  the  velum, 
or  even  to  a  slight  extent  into  palate  bones,  the  operation  is  more 
complicated,  for  every  attempt  to  bring  the  edges  of  the  fissure  to- 


1  G.  Tollock. 

8  Sir  \V.  Fergusson;  F.  H.  Hamilton. 


2  T.  Holmes;  G.  Pollock;  T.  Bryant 
4  W.  R.  Whitehead. 


THE  PALATE. 


353 


getlier  is  opposeil  l)y  thi-  comljiiitMl  actions  of  the  levator  and  tensor 
palati  nuisck-s,  on  uitlier  t'ide,  drawinj;  <lirectl\-  away  from  the  me- 
dian line  at  which  tlie  edges  of  the  fissure  should  meet;  these  muscles 
must  therefore  be  divided  to  insure  success.^ 
The  relaxation  of  the  tissues  of  the  fissured 
velum  may  gem-rally  be  suHiciently  secured 
by  means  of  incisions  made  with  strong  curveil 
scissors,  so  as  to  divide  the  posterior  pillar  of 
the  palate  jist  where  it  begins  to  spread  out 
into  the  velum;  in  some  cases  an  additional 
stroke  or  two  of  the  scissors  is  necessary  to 
diviile  a  band  of  firm  tissue  extending  above 
and  behind  the  soft  |)alale.'*  The  division  of 
the  muscles  is  also  effected  as  follows:  pass  a  Fig.  322. 

suture  through  one  section  of  the  soft  palate  at  the  root  of  the  uvula, 
secure  the  emls  by  a  knot,  and  have  it  held  outside  the  mouth;  re- 
peat a  similar  suture  on  the  opposite  side  ;  draw  one  of  the  sutures 
firmly,  holding  one  half  of  the  soft  palate  to  its  opposite  side  so  as  to 
stretch  this  section  of  the  palate  towards  the  median  line;  recognize 
the  hamular  process  in  the  substance  of  the  soft  palate  internal  and 
a  very  little  posterior  to  the  last  molar  tooth;  introduce  the  point  of 
a  thin,  narrow  knife  fixed  in  a  long  handle,  the  blade  down,  a  little 
in  front  and  to  the  inner  side  of  this  process  and  carry  it  upwards, 
backwards,  and  somewhat  inwards,  until  the  point  is  seen  in  the  gap, 
having  passed  through  the  entire  thickness  of  the  soft  palate,  and 
cut  partially,  if  not  wholly,  the  tendon  of  the  tensor  palati;  raise 
the  handle  of  the  knife,  depressing  its  point,  and  as  the  blade  is 
drawn  forward  make  it  cut  downwards  so  as  to  pass  through  a  con- 
siderable .section  of  a  circle  on  the  posterior  surface  of  the  palate,  by 
which  the  division  of  the  greater  portion  of  the  levator  palati  is  ef- 
fected ;  complete  its  section  as  the  knife  is  withdrawn. 

If  the  muscle  is  properly  divided  all  movements  of  the  palate  ceasej  and  it 
becomes  pendulous  and  flaccid ;  if  there  be  any  further  resistance,  reintroduce 
the  knife  and  divide  the  fibres  more  freely. i  Tlie  divisions  of  the  muscles  may 
be  made  a  day  or  two  before  the  operation  for  closiufj  tiie  lissure  and  thus  avoid 
the  bleeding ;  '^  or  the  nuiseles  may  be  divided  after  paring  the  edges,  and  in- 
serting the  sutures,  the  palate  being  put  on  the  stretih  by  means  of  the  threads 
held  in  the  hand:*  lateral  incisions  through  the  soft  parts  completely  dividing 
the  soft  palate  from  its  lateral  attachments  will  allow  the  two  halves  to  fall  to- 
gether.^ 

The  edges  of  the  fissure  should  now  be  thoroughly  denuded  of 
mucous  membrane,  and  the  sutures  inserted. 


1  G.  Pollock. 
6  T.  Bryant. 


•i  .1.  M.  Warren. 


23 


3  G.  W.  Calleuder. 


*  T.  Smith. 


354 


OP  Eli  A  TIVE   S  UR  GER  Y. 


Of  the  various  instruments  for  inserting  the  thread,  the  spiral  needle,  e  (Fig. 
316),  is  the  best,  but  the  common  curved  needle  with  a  firm  needle-holder,  i  (Fig. 
316),  may  answer  in  emergencies. ^ 

First  decide  how  many  sutures  will  be  required,  and  observe  the 
points  at  which  they  should  be  inserted  to  correspond  on  each  side; 
the  sutures  in  each  needle  should  be  at  least  one  yard  in  length,  and 
each  suture  should  be  doubled  for  its  whole  length  before  being 
passed  ;  with  the  needle  in  the  right  hand  and  a  pair  of  long  spring 
forceps  in  the  left,  push  the  point  of  the  needle  through  the  soft  pal- 
ate on  the  patient's  left  side,  as  near  to  its  anterior  margin  as  prac- 
ticable; seize  one  thread  of  the  suture  and  draw  it  forwards;  pass 
the  needle  on  the  opposite  side  with  a  double  thread,  the  loop  of 
which  should  be  drawn  out;  the  needles  being  removed,  the  single 
thread  of  the  one  side  is  passed  through  the  loop  of  the  other,  the 
looped  thread  withdrawn  from  the  palate  carrying  the  single  suture 
through  the  opposite  side  (Fig.  323)  ;2  repeat  until  the  requisite 
number,  three  or  four,  is  inserted;  tie  each  separately,  and  not  too 

tightly,    to    allow   for 

swelling;    a   slip-knot 

(Fig.  323)  to  bring  the 

edges  together,  and  a 

second  knot  over  that, 

are      suHicient     (Fig. 

324);  the  ends  should 

not    be    cut   off    very 

close.3      A   perforated 

shot  may  be  passed 
over  the  suture,  and  a  knot  tied  to  prevent 
slipping  (Fig.  326).  If  wire  is  used,  it  must  be 
applied  with  the  wire  adjuster,  c  (Fig.  316),  be  nicely  twisted,  and 
cut  closely.  The  after  treatment  must  be  carefully  attended  to;  the 
diet  should  be  liquid;  no  conversation  should  be  allowed;  the  su- 
tures may  be  removed  after  about  eight  days. 

2.  Uranoplasty,  closure  of  fissure  of  the  hard  palate,  may  be  un- 
dertaken at  any  age,  yet  as  the  real  object  of  the  operation  is  to  ena- 
ble the  patient  to  articulate  plainly  and  intelligibly,  and  as  a  child 
does  not  conunence  to  articulate,  as  a  rule,  before  twelve  months  old, 
nor  to  pronounce  many  words  before  two  years  of  age,  the  reasons 
are  strong  against  its  performance  prior  to  this  latter  period  of  life, 
for  the  child  is  now  in  a  much  more  favorable  condition  to  undergo 
the  operation,  and  less  liable  to  succumb  to  the  effects  of  the  loss  of 
blood.  'J'he  early  treatment,  therefore,  is  the  proper  nourishment 
of  the  infant  until  it  reaches  the  requisite  age,  and  the  mother's 
1  F.  H.  Hamilton.  2  j.  Bell.  3  q.  Pollock. 


Fig.  3-23. 


Fig.  324. 


THE  PALATE.  355 

milk  is  the  only  food  tliat  should  be  j^iven  for  the  first  six  or  eight 
weeks;  if  the  child  cannot  nurse,  owing  to  tlie  extent  of  the  cleft,  it 
must  be  hand-fed  with  her  niilk.^  The  operation,  whatever  may  be 
the  extent  of  the  fissure,  consists  in  dissecting  up  ihe  membrane  cov- 
ering the  hard  palate,  (juite  back  to  the  alveolar  processes,^  including 
the  periosteum  so  as  to  form  muco-periosteal  flaps. ^  The  result  will 
be  successful  in  any  case  where  the  patient  is  fairly  healthy  and  the 
parts  can  be  Ijrought  to'iethcr  without  undue  tension.*  The  closure 
is  effected  not  oidy  by  these  soft  tissues,  but  also  by  bone  subse- 
quently reproduced  in  the  periosteal  layer.^  As  the  success  of  the 
operation  depends  upon  iininecliate  union  of  the  edges  of  the  flaps, 
examine  the  patient  carefully  to  ascertain  if  he  is  in  a  condition  of 
health  to  justify  the  expectation  of  union  by  first  intention;  if  there 
are  any  signs  of  disordered  health  or  defective  power,  as  pustules, 
herpes,  excoriated  lips  or  nostrils,  the  operation  should  be  postponed.^ 
The  operation  may  be  completed  at  one,^  or  at  several  sittings;^  un- 
less there  are  circumstances  of  peculiar  difficulty  in  the  case  which 
will  make  the  operation  either  unusually  tedious  or  will  necessitate 
such  an  extensive  division  of  the  soft  parts  as  would  endanger  the 
flaps,  the  whole  cleft  should  be  closed  at  one  operation.* 

In  an  ordinary  case  of  cleft  of  the  hard  and  soft  palate  proceed  as 
follows:  Place  the  patient,  etherized,  in  a  good  light;  introduce  the 
gag  previously  fitted  to  the  mouth  (Big.  317);  or,  if  the  cleft  is 
through  the  alveolar  process  also,  select  a  gag*  which  has  no  central 
roof  portion.^  Operate  first  on  the  soft  palate;  pare  the  edges  of 
the  cleft  from  below  upwards,  the  point  of  the  uvula  being  held 
with  forceps,  h  (Fig.  316),  to  render  it  tense;  apply  the  sutures 
from  below  upwards,  passing  them,  if  possible,  conii)letely  through 
both  sides  to  avoid  the  loops  described,  and  fastening  each  after  the 
next  is  passed  ;  relieve  the  undue  tension  by  longitudinal  incisions 
on  either  side  parallel  with  the  cleft,  and  just  internal  to  the  hara- 
ular  process,  avoi<ling  the  post  palatine  foramen,*  or  cut  the  mus- 
cles, seizing  with  the  forceps,  h  (Fig.  316),  the  palato-pharyngeus 
muscles  and  dividing  them  with  the  scissors, y  (Fig.  31C),  low  down, 
and  also  the  levator  palati,  of  both  sides.''  When  the  soft  palate 
has  been  closed  and  the  point  in  the  velum  has  been  reache<l  where 
the  sutures  can  no  longer  be  fastened,  from  the  anioimt  of  tension, 
proceed  to  operate  on  the  hard  palate,  if  the  condition  of  the  pa- 
tient do  not  foriiid  it.*  Separate  the  soft  tissues  from  the  bone,  com- 
mencing at  the  edge  of  the  cleft  and  dissecting  outwards  to  the  alve- 
olar process;  2  or,  which  may  be  preferable,  from  the  alveolar  border 
towards  the  fissure,*  as  follows  :  make  an  incision  close  to  and  par- 

1  G.  Pollock.  2  J.  Ji.  Warren.  8  Von  Langenbeck.  *  T.  Smith. 

6  Von  I.angenbcrk:  \V.  R.  Whitehead.     6  J.  L.  Little.     "  W.  R.  Whitehead. 

8  G.  Pollock;  W.  K.  Whitehead;  Vou  Langenbeck;  P.  Mason. 


356  OPERATU^  SURGERY. 

allel  with  the  alveolar  ridge,  from  a  point  opposite  tlie  last  molar 
tooth  forwards  to  the  canine,  and  separnte  the  flaps  from  the  bone 
by  means  of  the  periosteotorae,  /i,  i  (Fig.  31G),  commencing  at  the 
incisors  and  proceeding  inwards  to  the  edge  of  the  gap,  avoiding 
bruising  the  flaps  ;  these  flaps  should  now  fall  inwards  and  down- 
wards and  meet  in  the  median  line  without  the  slightest  traction;  if 
the  edges  do  not  readily  meet,  the  flaps  have  not  been  sufliciently 
detached,  and  search  must  be  made  for  the  point  preventing  aescenJ, 
which  should  be  freely  liberated;  pare  the  edges  with  a  sharp  knife 
so  that  two  entire  and  fresh  raw  surfaces  are  brought  accurately  in 
contact;  pass  the  sutures  as  in  closure  of  the  soft  palate.^  No  special 
treatment  is  required,  except  to  avoid  giving  warm  food  until  the 
day  after  the  operation,  and  to  abstain  from  looking  at  the  palate; 
give  first  iced  milk,  and  afterwards,  for  a  fortnight,  such  food  as 
e<T"'s,  milk,  rice  milk,  cream,  custard,  stewed  fruit,  arrowroot,  soup, 
beef  tea,  pounded  meat,  with  wine,  brandy,  or  malt  liquors;  children 
and  delicate  young  persons  should  be  kept  in  bed  for  a  week,  when 
practicalile;  the  sutures  should  remain  three  weeks  or  a  month  in 
chililren,  and  be  removed  under  an  anajsthetic.^ 

It  frequently  happens  that  under  the  most  favorable  circumstances  a  small 
aperture  will  remain;  these  openings  are  not  unlike  those  slight  congenital  de- 
fects which  appear  in  the  palate  as  orifices,  or  which  result  from  syphilitic  ca- 
ries; they  may  be  closed  with  a  metal  plate, ^  or  with  a  hard  rubber  obturator,^ 
or  by  subsequent  operations.* 

II.  CONTRACTION  OF  SOFT  PALATE. 

Contracted  soft  palate  frequently  results  from  successful  clos- 
ure of  the   cleft,  and  leads  to  imperfect  speech.     With  a  view  to 
leno-then  the  curtain  or  relieve  the  tension  upon  it,  several  operations 
-  have  been  performed:  (1.)  The  inner  bor- 

/!'■ >■'"     '  Vs-,  ■,   <^crs  of  the  palato-pharyngeus  muscles  have 

4     /  ff-o      ^^        been  pared  and  united,  but  the  operation 

n  -'i  "' S  .../X\.---    li;i*l  the  effect  of  compelling  the  patient  to 

/\^ SL'^  ^"^""^  \      ^''^'''ithe  entirely  through  the  mouth,  with- 

/ni  W     out  improving   speech. ^     (2.)  The  attach- 

l  J^ — ^^-^-"^        N.  \    ments  of  the   palate    to   the    sides   of   the 

//  rr^  Vi   fauces,  to^'ether  with  the  anterior  and  pos- 

/  \  terior  pillars   may   be   divided   as  follows: 

'  '  pass   a  spatula  behind  the  soft  {)alate,  1,  2 

(Fig.  325)  both  to  steady  and  to  draw  it 
forward,  then,  transfix  the  soft  palate  by  a  sharp  pointed  bistoury  by 
the  side  of  the  spatula  and  at  the  inner  edge  of  the  haniular  pro- 

1  G.  Pollock.         2  T.  Smith.         3  j.  M.  Warren.         *  W.  R.  Whitehead. 
5  Passavant. 


TUE  PALATE. 


357 


cess  1,  4,  and  cut  tliroiifih  the  free  margin  of  the  palate  to  2  {Y\<^. 
325),  dividing  tiie  tensor  palati,  palato  glossus,  and  palatopharynger.s 
muscles;  retraction  fullows,  3;  sutures  are  now  passed  througli  the 
sides  of  the  flap  from  before  backwards,  tlius  hcniniing  the  mucous 
membrane,  5;  this  operation  is  extremely  simple,  conii)aratively 
painless,  and  has  always  resulted  in  some,  and,  in  many  instances 
marked,  improvement  of  the  voice. ^  (3.)  Dissection  of  the  palato- 
pharyngeus  muscles  to  form  flaps  in  connection  with  a  raised  portion 
of  the  mucous  membrane  of  tlic  prevertebral  region  was  attempted 

but  not  completed. - 

III.    TIIE  UVULA. 

The  special  instruments  adapted  to  operations  on  the  uvula  are  (Fig.  -328): 
forcei).s  for  holding  the  tongue,  a;   a  vulsellimi, 
h;  uvula  scissors  with  claws,  c;  a  uvulatonie, 
d ;  double  hook,  e.-* 

1.  Elongated  uvula  is  the  result  of* 
chronic    inflammation  ;    the    lengthening 
may  be  slight  or  so  great  as  to  fall  into 
the  laryn.x.     Excision,  a  very  simple  op- 
eration,^ should  be  performed  thus:  the 
patient  sitting  upon  a  chair  in  front  of  a 
goofl  light,  seize  the  tongue  with  the  broad 
spatula,  a,  or  direct  the  patient  to  with- 
draw it  from  the  mouth  by   seizing  the 
tip  enveloped  in  a  handker- 
chief ;  seize  the  apex  of  the 
uvula  with  the  forceps,  i,  or 
double  hook,  e,  and  cut  off 
■with    the    serrated    scissors 
slightly  curved,  c,  or  uvula- 
tome,    d    (Fig.    326),    aliout 
two  thirds  of  the  organ. 

2.  Abscess  occasionally  forms  in  the  soft  palate  as  a  result  of  in- 
flammation which  often  extends  from  the  tonsils;  when  pus  is  recog- 
nized, puncture  with  a  knife  having  a  sharp  point  and  a  narrow 
blad(-';   pass  this  directly  l)ackwards. 

3.  Tumors  appear  in  the  .soft  palate,  and  arc  either  fibro-celliilar, 
cystic,  or  warty  ;  the  former  are  usually  pendulous,  attached  to  the 
free  border  or  upper  surface  of  the  palate,  of  slow  growth ;  remove 
them  with  forceps  and  scissors.  Cysts  result  from  obstructed  ducts, 
commonly  contain  thin  glairy  fluid,  and  are  treated  by  incision  and 
the  application  of  nitrate  of  silver.  Warty  growths  springing  from  the 
mucous  membrane   should  be  removed  with  scissors. ^     Polypi  may 

1  F.  :\[.i>^on.  ^  W.  K.  Whitehead.  »  11.  Green.  ^  S.  D.  Gross. 

5  G.  I'ollock. 


Fig.  .320. 


358  OPERATIVE  SURGERY. 

appear  on  the  posterior  surface,  and  give  rise  to  cough  owing  to  their 
pendulous  condition  ;  they  may  be  easily  removed  with  scissors.* 


CHAPTER    XXXn. 

THE    ALVEOLAR    PROCESS;    THE    SALIVARY    GLANDS; 
THE    TONSILS. 

I.     THE  ALVEOLAR  PROCESSES. 

These  parts  are  the  thick  pyramidal  ridges  of  the  maxillae  which 
arch  from  behind  forward  and  inward  ;  the  free  margins  present  the 
orifices  of  a  number  of  deep  conical  pits,  the  sockets  for  the  insertion 
of  the  teeth;  the  outer  surface  is  marked  by  alternating  vertical 
rid"-es  and  depressions  corresponding  with  the  alveoli  and  their  in- 
terval s.^ 

1.  Abscess  is  caused  by  inflammation  of  the  alveolo-dental  peri- 
osteum. A  sac  forms  at  the  a])ex  of  the  tooth  which  finally  suppu- 
rates with  absorption  of  the  fluid;  the  gums  swell  and  become  pain- 
ful, the  accumulated  pus  ultimately  makes  an  opening  through  one 
side  of  the  socket,  opposite  the  extremity  of  the  root,  the  pain  mean- 
time is  deep-seated  and  throbbing  until  the  pus  escapes. ^ 

The  pointing?  of  the  abscess  upon  the  face  appears  to  depend  upon  either  an 
unusual  length  of  fang  or  a  superficial  reflection  of  the  mucous  membrane  from 
the  jaw  to  the  cheek.* 

In  an  early  stage  prevent  suppin-ation  by  means  of  leeches  or  the 
extraction  of  the  tooth  or  its  filling;  when  pus  is  detected,  punc- 
ture with  a  sharp-pointed  knife ;  if  it  threaten  to  open  externally, 
remove  the  tooth  and  make  an  incision  between  the  cheek  and  the 
jaw  so  as  to  cut  aci'oss  the  pus-containing  canal,  and  dress  the  wound 
with  oiled  lint  to  prevent  union.* 

2.  Epulis  is  an  innocent  tumor,  hard,  and  densely  fibrous,  com- 
posed of  fibrous  tissue  and  myeloid  cells,  and  involving  the  perios- 
teum; it  grows  slowly  and  evenly  from  the  edge  of  the  alveolar  proc- 
ess, usually  between  two  standing  teeth,  more  often  on  the  external 
than  internal  surface,  though  it  may  spring  from  any  part;  it  gener- 
ally makes  its  first  appearance  beneath  and  involving  the  little  tongue 
of  gum  which  exists  between  the  necks  of  two  contiguous  teeth; 
finally  it  displaces  the  neighboring  teeth,  one  usually  more  than  the 
other,  has  a  broad  base,  which  increases  more  the  projecting  portion. 
The  treatment  is  early  and  complete  extirpation,  not  only  of  the 
tumor,  but  the  teeth  and  all  the  gum  from  which  it  sprung;  while 
any  part  of  the  gum  remains  it  is  likely  to  recur.*     Excision  is  best 

1  S.  C.  Bussy.  2  J.  Leidy.  8  c.  A.  Harris.  *  J.  A.  Salter. 


THE  ALVEOLAR  PROCESS.  359 

effected  by  strong  cutting  bone  forceps.  Extract  tlie  involved  teeth, 
and  then  cut  the  process  on  both  sides  of  the  growth  completely 
through  the  alveolar  border,  and  remove  the  mass  with  a  knife  or 
bone  nippers. 

3.  Hypertrophy  appears  as  a  congenital  affection,  and  consists  of 
an  expanded  and  j)roIonged  development  of  the  alveolar  borders  of 
the  maxilliu,  immense  thickening  of  the  fibrous  tissue  of  the  gum, 
and  exul)erant  growth  of  the  papillary  surface.  When  fully  devel- 
oped, the  patient  presents  an  extraordinary  ajipearance  —  a  large 
mass,  deii?e,  inelastic,  insensitive,  pink  and  smooth,  jjrotrudes  from 
the  mouth. 1      Excision  slioidd  be  j)erformed. 

4.  Vascular  grow^ths,^  na;vi  and  aneurisms  by  anastomosis  form 
in  the  tissues  about  the  necks  of  the  teeth,  especially  between  the  in- 
cisors or  canines  and  lateral  incisors  of  the  upper  jaw;  they  have  a 
purplish  color,  are  smooth  and  streaked,  with  many  vessels,  are  easily 
compressed  and  become  pale  and  reduced,  but  are  elastic  and  resume 
their  previous  aspect  on  removal  of  pressure ;  the  whole  gum  is  red, 
turgid,  and  swollen,  and  the  little  tongues  of  gum  between  the  necks 
of  the  teeth  are  enlarged  and  spongy;  troublesome  haemorrhage  oc- 
curs later  in  the  disease.  Excision  should  be  performed  with  a 
scalpel,  the  bleeding  being  controlled  by  pressure  and  ice. 

5.  Warty  gro^^rths '  are  hypertrophied  papillaj  of  the  gum,  which 
occasionally  appear,  sometimes  in  connection  with  warts  on  the  lips 
and  about  the  face.  Excision  should  be  practiced;  and  if  there  is  a 
return  caustics  should  be  applied. 

6.  Tooth  tumors.^  odontomes.  spring  from  the  hard  tissues  of  the 
teeth,  and  arc  rlassilied  as  follows:  (1)  enamel  nodules,  pearl-like 
tumors  on  the  fangs;  (2)  exostoses,  small  rounded  nodules  near  the 
apex  of  the  fang;  (3)  hypertrophy  of  fangs;  (4)  dentine  excres- 
cence, nodules  of  secondary  dentine  growing  from  the  wall  of  the 
pulp-chamber  ;  (5)  warty  teeth,  the  tissues  being  hypertro|)hied  and 
folded  into  an  irregular  and  complicated  mass.  Extraction  of  the 
affected  tooth  is  necessary  when  the  symptom=.  as  severe  neuralgia, 
or  the  degree  of  malformation,  demand  interference. 

7.  Dentigerous  cysts  ^  are  collections  of  serum  in  the  maxillary 
bones,  depeniKnt  upon  impacted  misplaced  teeth  ;  they  arise  only 
when  the  tooth  or  teeth  associated  with  them  are  imbedded  in  the 
substance  of  the  jaw-bone  and  do  not  occur  after  the  tooth  has 
pierced  the  gum;  they  occur  in  connection  with  the  permanent  teeth 
which  may  fail  to  pierce  the  gum,  either  from  the  great  depth  of  the 
sac,  or  growth  in  an  oblique  direction,  or  from  arrest  of  development. 
The  symptoms  are,  expansion  of  the  jaw-bone,  weight,  and  tension, 
and  disfigurement  of  the  features;  the  diagnosis  depends  on  pressure, 

1  J.  A.  Salter. 


360  OPERATIVE  SURGERY. 

■which  i-eveals  fluid,  expansion  of  bone,  and  crepitation  Uke  stiff 
parchment,  and  absence  of  a  tooth  or  teeth  which  have  never  ap- 
peared. The  treatment  consists  in  opening  tlie  cyst  freely  with 
knife,  gouge,  or  trephine,  extraction  of  the  imbedded  tooth,  and,  if 
the  expansion  is  hxrge,  removal  of  the  dilated  bone;  the  result  is 
always  satisfactory. 

8.  The  extraction  of  teeth,^  though  not  strictly  belonging  to  the 
province  of  the  medical  practitioner,  must  frequently  be  performed 
by  him. 

It  is  surprising  that  this  operation  should  receive  so  little  attention  ;  this  neglect 
can  only  he  accomited  for  by  the  too  prevailing  belief  that  little  or  no  skill  is 
required  for  its  performance;  but  it  is  the  duty  of  every  physician,  residing 
where  the  services  of  a  skillful  dentist  cannot  always  be  connnanded,  to  pro- 
vide liiuiself  wiih  the  proper  instruments  and  become  acquaiutid  with  the  man- 
ner of  performing  this  operation. 

The  indications  for  the  extraction  of  the  temporary  and  j)erma- 
nent  teeth  are  as  follows:  — 

(1.)  When  a  tooth  of  replacement  is  about  to  emerge  from  the  gums,  or  has 
actually  made  its  appearance,  either  before  or  behind  the  corresponding  milk 
tooth.  (2.)  When  the  aperture  formed  by  the  loss  of  a  temporary  tooth  is  so 
narrow  as  to  prevent  the  permanent  tooth  from  acquiring  its  proper  position 
without  the  removal  of  an  adjuiuing  temporary  tooth.  (3.)  Alveolar  abscess, 
necrosis  of  the  walls  of  the  alveolus  and  incurable  pain  in  a  temporary  tooth. 
The  indications  for  the  extraction  of  the  permanent  teeth  are:  (1)  when  a  molar 
has  become  partially  displaced,  or  is  a  source  of  constant  irritation;  (2)  when 
there  is  a  constant  discharge  of  fetid  matter  from  the  nerve  cavit}'  through  a 
carious  cavity  in  the  crown,  unless  the  discharge  is  slight,  and  the  tooth  is  in 
tiie  front  part  of  the  mouth  and  cannot  be  easily  replaced;  (3)  when  a  tooth  is 
the  cause  of  an  incurable  alveolar  abscess,  unless  the  previous  conditions  exist ; 
(4)  when  there  is  irregularity  of  the  tooth  due  to  disproportion  between  the  size 
of  the  teeth  and  the  alveolar  arch;  (5)  when  dead  teeth  act  as  irritants,  or  have 
become  very  much  loosened. 

Teeth  may  be  extracted  with  the  key  or  with  forceps.  The  com- 
mon tooth-key  is  a  wheel  and  axle,  the  hand  of  the  operator  acting 
on  two  spokes  of  the  wheel  to  move  it  while  the  tooth  is  fixed  to  the 
axle  by  the  claw.^  The  straight  shank,  with  a  small  round  fnlcruni 
slightly  flattened  on  each  side,  is  preferable  to  any  otlier;  there 
should  be  several  hooks  of  different  sizes,  the  edges  of  which  should 
resemble  the  eagle's  claw;^  operate  as  follows  :  separate  the  gum  from 
the  neck  of  the  tooth  down  to  the  alveolus,  and  round  the  entire 
tooth,  with  a  straight,  narrow-bladed  knife,  pointed  at  the  end  and 
with  one  cutting  edge;  attach  the  proper  hook,  and  api)ly  the  fulcrum 
upon  the  inside  of  the  edge  of  the  alveolus,  the  extremity  of  the 
claw  being  pressed  down  upon  the  neck  on  the  opposite  side,  grasp 
the  handle  with  the  right  hand,  and  hy  a  firm,  steady  rotation  of  the 
wrist,  raise  the  tooth  from  its  socket.^ 

1  C.  S.  Harris.  2  Arnot. 


THE  ALVEOLAR  PROCESS. 


361 


For  the  removal  of  a  tootli  on  tlie  left  side  of  tlie  lower  jaw,  or  the  right  side 
of  the  upper,  tlie  palm  t^hould  be  beneath  the  handle; 
for  the  other  teeth  it  should  be  jibove;  where  the  exter- 
nal surface  of  the  tooth  is  decayed,  the  fulcrum  must  be 
placed  on  the  outside  (Fig  327). 

The  forct'ps  are  to  be  preferred  to  the  key,  for 
in  the  niajority  of  cases  they  can  be  used  with 
greater  ease,  and  much  less  ])ain.  ThouLjh  there 
is  a  great  variety  of  forms,  but  four  are  required 
for  general  use.  These  are  arranged  in  two  sets, 
one  adapted  for  the  incisors,  o,  below,  and  b, 
above  (Fig.  328)  and  cuspids,  and  the  other  for  Fig.  327. 

the  bicuspids  and  molars,  c.  below,  and  d,  above. 
Operate  as  follows:  detach  the  gum  from  the  neck  of  the  tooth,  un- 


FiG.  328.1 

less  the  claw  of  the  forceps  is  sharp  and  sufficiently  separates  it; 

grasp  the  tooth  firmly  at  the  alveolar  edge,  but 

do  not  compress  the  handles  of  the  forceps  too 

tightly;  move  the  tooth  outwards  and  inwards, 

in  (piick  succession,  until  it  is  loosened,  and 

then  draw  it  from  its  socket  in  a  line  with  its 

normal  axis. 

For  the  incisors,  strong,  straight  forceps  may  be 
used  (Fig.  329),  and  a  slight  rotary  motion  should  be 
given  to  the  tooth  ;  the  cuspids  reipiire  greater  force, 
due  to  the  length  of  their  roots:  very  little  rotary  mo- 
tion can  be  given  to  the  bicus|)i(ls;  the  upper  molars 
have  three  roots,  are  very  firm,  and  must  be  grasped 
as  high  up  as  possible  and  pressed  out  and  in  uiuil  it  yields;  the  superior  dentes 
1  Geo.  Tiemauii  &  Co. 


362  OPERATIVE  SURGERY. 

sapientise  are  usually  less  firmly  articulated  and  are  easily  removed  with  the 
bicuspid  forceps;  the  inferior  molars  have  two  roots,  but  are  very  firm,  and  the 
decayed  tooth  is  liable  to  be  overlapped  by  the  crowns  of  the  adjoining  teeth, 
which  mav  require  filing  off  to  admit  of  removal;  the  dentes  sapicntiiB  of  the 
lower  jaw,  when  situated  far  back,  are  oftentimes  exceedingly  difficult  to  ex- 
tract, especially  when  the  roots  are  turned  posteriorly  towards  the  coronoid  pro- 
cess ;  in  this  case  the  loosened  tooth  should  be  pushed  backwards,  describing 
the  segment  of  a  circle  as  it  is  raised. 

II.     THE    SALIVARY  GLANDS. 

These  form  a  series  of  conglomerate  glands  arranged  in  a  curved 
manner,  and  following  the  circumference  of  the  inferior  maxiUa  from 
the  posterior  border  of  one  side  to  that  of  the  other,  and  pouring 
their  secretion  into  the  moutli  by  means  of  excretory  ducts.^ 

1.  The  parotid,  the  largest  in  the  series,  is  bounded  above  bv  the  zygoma; 
below  by  a  line  drawn  backwards  from  the  lower  border  of  the  jaw  to  the 
sterno-mastoid  muscle;  behind  by  the  external  meatus  of  the  ear,  tlie  mastoid 
process,  and  sterno-mastoid  muscle;  its  anterior  border  lies  over  the  ramus  of 
the  lower  jaw,  and  stretches  forward  to  a  variable  extent  on  the  masseter  muscle ; 
the  deeper  parts  extend  far  inwards  between  the  mastoid  process  and  the  ramus 
of  the  jaw  towards  the  base  of  tlie  skull;  the  excretory  ducf^  passes  off  from 
the  anterior  border  of  the  gland,  one  finger's  breadth  below  the  zygoma,  runs 
forwards  over  the  masseter  muscle  to  the  anterior  border,  turns  inwards  through 
the  fat  of  the  cheek,  pierces  the  buccinator  muscle,  runs  a  short  distance  ob- 
liquely forwards  beneath  the  mucous  membrane,  and  opens  upon  the  inner  sur- 
face of  the  cheek  by  a  small  orifice  opposite  the  crown  of  the  second  molar  tooth 
of  the  upper  jaw;  a  line  drawn  from  the  middle  of  the  upper  lip  to  the  meatus  of 
the  ear  marks  the  course  of  the  duct.^ 

2.  The  submaxillary  is  situated  immediately  below  the  base  and  the  inner 
surface  of  the  lower  jaw  and  above  the  digastric  muscle;  its  duct, ^  two  inches 
in  length,  passes  off  from  the  gland  to  the  side  of  the  fraenum  lingua',  where  it 
terminates  close  to  the  duct  of  the  opposite  side  bj'  a  narrow  orifice  which  opens 
at  the  summit  of  a  soft  papilla  beneatli  the  tongue. ^ 

3.  The  sublingual,  the  smallest  gland,  is  situated  along  the  floor  of  the 
mouth,  where  it  forms  a  ridge  between  the  tongue  and  the  gums  of  the  lower 
jaw,  covered  only  by  the  mucous  membrane,  and  reaching  from  the  fnenum  in 
front,  where  it  is  in  contact  with  the  gland  of  the  opposite  side,  obliquely  back- 
wards and  outwards  rather  more  than  an  inch  and  a  half;  the  ducts  5  are  from 
eight  to  twenty  in  number  and  open  along  the  ridge  which  indicates  tiie  position 
of  the  gland.** 

1.  "Wounds  involving  these  glands  are  not  liable  to  bo  followed 
by  fistula,  for  though  saliva  flows  for  a  time  through  the  incision  the 
textures  consolidate,  and  the  wounded  part  is  obliterated.  If  oozing 
of  saliva  prevent  healing  apply  pressure,  or  touch  the  part  with  hot 
wire,  when  the  fistulous  opening  will  usually  promptly  close  ;  if  the 
excretory  duct  is  wounded,  as  of  the  parotid  gland,  it  is  important 
to  complete  the  incision  into   the  mouth,  if  it  has  not  penetrated  so 

1  Cyclop.  Anat.       ^  Steno's.       3  Quain's  Anat.       *  Wharton's.       ^  Rivieri. 


THE  SALIVARY   GLAXDS.  363 

deeply,  to  allow  a  free  escape  of  the  saliva  in  that  direction,  and  close 
the  external  wound  with  silver  suture.* 

2.  Abscess  may  form,  especially  in  the  parotid,  and  generally 
run-i  an  acute  course  with  much  excitement;  the  pain  is  excessive, 
the  parts  pit  on  pressure,  there  is  inability  to  open  the  moutli,  the 
fluctuation  is  obscure  as  the  pus  is  Hrmly  bound  down  by  the  fascia 
and  capsule  of  the  gland;  the  treatment  is  early  and  free  incision, 
made  vertically  into  the  most  prominent  part.*  Abscess  may  form 
in  the  course  of  the  ducts  from  obstruction  by  concretions;  in  the 
parotid  duct  it  appears  as  a  soft,  fluctuating  swelling  in  the  cheek, 
which  may  attain  large  size,  but  usually  ulcerates  w^hen  quite  small 
and  opens  externally;  in  the  subma.xillary  and  sublingual  ducts  these 
abscesses  open  into  the  mouth;  the  obstruction  should,  if  possible,  be 
dislodged,  and  the  abscess  opened  within  the  mouth;  if  the  abscess 
of  the  cheek  cannot  be  relieved  it  should  be  opened  into  the  mouth, 
and  the  obstruction  removed. 

3.  Calculi  may  form  in  any  of  the  ducts-  of  the  salivary  glands, 
but  the  suljlingual  and  submaxillary  are  most  frequently  affected ; 
they  are  generally  of  an  ovoid  shape,  whitish  color,  rough,  conqjosed 
of  phosphate  and  carbonate  of  lime  with  animal  matter;  when  diag- 
nosed tiny  should  be  removed  within  the  mouth  by  incision.- 

4.  Fistulas  may  remain  after  wounils  or  abscesses  involving  either 
the  glands  or  ducts  which  open  externally.  Fistula  of  the  "_dand,  fully 
establislied,  is  often  very  difhcult  of  cui-e.  The  means  which  may  be 
adopted  are,  (1)  injections  of  iodine;  (2)  cauterization:  (3^  grad- 
uated compression  ;  (4)  plastic  operations.  When  the  parotid  duct 
is  implicated,  the  first  step  in  the  process  of  cure  is  to  establish  a 
free  opening  into  the  mouth,  from  the  oral  end  of  the  duct;  pass  a 
fine  probe,  armed  with  several  threads  of  silk,  into  the  fistula,  through 
the  duct,  into  the  mouth  either  direct  or  through  the  natural  open- 
ing; draw  the  end  of  the  seton  in  the  mouth  out  at  the  anoxic  and  tie 
it  to  the  end  on  the  cheek :  after  a  week  or  ten  days  the  artificial  fis- 
tulous communication  with  the  mouth  will  be  established,  and  the 
fistula  in  the  cheek  will  then  probably  contract  and  close;  if  it  do 
not,  cauterization  of  the  edges  of  the  fistula  will  tend  to  hasten 
cicatrization.'  This  operation  failing,  pass  a  thread  of  silk  or  metal 
through  the  fistula,  into  the  mouth,  from  before  backwards;  remove 
the  needle,  leaving  the  thread  in  place ;  thread  the  external  end  and 
reinsert  the  needle  at  the  fistula  and  carry  it  forwards  in  a  similar 
manner  into  the  mouth;  remove  the  needle  and  tie  the  two  ends  of 
the  thread  now  within  the  mouth  quite  firmly;  the  loop  cuts  its  way 
out,  leaving  a  free  internal  opening  of  the  duct  ;  tlie  edges  of  the 
fistula  may  now  be  freshened  and  united  by  a  suture.*     Or,  the  fis- 

1  J.  Spence.  -  S.  D.  Gross.  »  Morand;  T.  Bryant.  *  J.  Bell- 


364  OPERATIVE  SURGERY. 

tulous  tract  may  be  destroyed  by  placing  a  wooden  spatula  against 
the  inside  of  the  cheek  and  witli  a  large,  sharp,  saddler's  punch  re- 
moving it  entire,  and  closing  the  external  opening  with  a  suture. ^ 

5.  Tumors  of  a  cartilaginous  nature  appear  by  preference  in  the 
salivarv  glands,  especially  in  the  sul:)maxillary  and  parotid.  Pure 
examples  of  enchondroma  are  more  often  found  in  these  glands  than 
anywhere  else.^  They  may  involve  a  single  or  several  lobes,  or  the 
entire  gland;  the  latter  is  rarely  found  in  the  pai-otid,  but  is  the  more 
frequent  form  in  the  submaxillary;  other  concomitant  affections  may 
also  be  present,  especially  myxoma,  and  sometimes  cancer  and  can- 
croid. ^  In  some  cases  the  cartilage  represents  merely  the  acme  of 
textural  evolution,  while  the  main  bulk  of  the  growth  is  made  up 
of  mucous  tissue,  with  spindle-cell  and  round-cell  sarcoma  tissue.* 
Tumors  of  these  glands  are  not  only  cartilaginous,  but  are  mostly 
encvsted,  and  have  a  peculiar,  hard,  elastic  feel,  are  generally  em- 
bedded in  the  structure  of  the  gland,  varying  much  in  depth,  those 
Avhich  appear  movable  and  superficial  too  often  dipping  well  down 
into  the  tissues;  they  may  grow  to  a  great  size,  and  stretch  the  skin 
over  them.^  The  question  of  the  removal  of  these  growths  must  be 
determined  by  the  conditions  existing  in  each  case;  pure  cartilag- 
inous tumors  of  small  size  may  be  very  easily  removed;  mixed  tu- 
mors of  large  size  involve  extensive  dissection  among  important 
parts,  but  they  are  often  removed  very  satisfactorily ;  cancerous  de- 
generation requires  extirpation  of  the  gland,  which  is  always  a  for- 
midable operation,  but  may  be  safely  accomplished  and  be  followed 
by  variable  periods  of  comparative  comfort^  A  safe  rule  to  follow 
may  be  thus  stated  :  when  it  is  evident  that  the  part  glides  freely 
over  the  subjacent  textures  do  not  hesitate  to  undertake  removal, 
whatever  may  be  the  bulk  of  the  disease;  but  if  the  tumor  seems 
fixed,  its  limits  not  clearly  defined,  and  its  movement  causes  jiain, 
hesitate  about  removal,  however  small  the  mass  may  be.'' 

Extirpation  of  the  tumor  requires  a  free  division  of  the  superim- 
posed parts  as  a  condition  essential  to  success;  make  first  an  incision 
down  to  the  tumor  and  through  its  investments,  and  then  add  others 
so  as  to  form  two  or  more  flaps;  carry  the  dissection  to  the  lower 
boundary  of  the  growth  where  the  vessels  are  known  to  enter,  and 
divide,  compress,  or  tie  them,  as  may  be  necessary,  and  thus  much 
less  blood  will  be  lost,  and  the  time  occupied  lessened ;  the  utmost 
care  must  be  taken  to  avoid,  as  far  as  possible,  the  branches  of  the 
cervical  nerves  and  the  portio  dura  by  dissecting  the  posterior  part 
of  the  tumor  careftdly,  and  in  the  direction  of  their  course,  the 
edge  of  the  knife  being  turned  towards  the  tumor;    in  some  cases 

1  \V.  E.  Horner;  S.  D.  Gross.  2  e.  Riiulfleisch.  3  R.  Virchow. 

4  T.  Billroth.         «  T.  Bryant.         6  j.  M.  Warren.         '  Sir  W.  Fergusson. 


THE  SALIVARY  GLANDS. 


365 


these  nerves  must  be  divided.^  Extirpation  of  the  entire  gland 
nin!<t  be  effected  by  similar  incisions  and  dissections,  but  in  deeper 
structures  the  handle  of  the  scali)el  must  be  used  as  far  as  possible 
to  detach  or  isolate  lol)es  of  the  i;land  or  portions  of  the  tumor  and 
disen^^a^:e  them  from  amon<^  the  vessels;  tearin;:^  out  the  loljes  is 
more  safe  than  incision;  in  extirpatinir  the  parotid,  the  greatest  pre- 
cautions should  l)e  taken  when  the  dissection  extends  beliind  the 
lower  jaw,  for  here  the  external  carotid  and  the  internal  and  maxil- 
lary arteries  are  found;  if  exposed,  they  should  be  tied  ;  the  styloid 
and  digastric  muscles  should  be  saved,  if  healthy,  and  cut,  if  in- 
volved in  the  disease;  if  the  tumor  finally  adhere  firndy  at  the 
upper  part,  apply  a  ligature  to  the  attachments;  the  arteries  liable 
to  be  involved  are  the  carotid,  transverse  facial,  temporal,  auricular, 
mastoid,  stylo-mastoid  occipital,  internal  maxillary,  the  inferior  pha- 
ryngeal, and  even  the  lingual  and  facial  ;  the  flaps  should  be  united 
by  suture,  proper  drainage  being  secured;  the  movements  of  the 
pharynx,  larynx,  tongue,  and  jaw  are  often  permanently  affected, 
anil  the  muscles  of  the  face  paralyzed. ^  In  extirpation  of  the  sub- 
maxillary, make  a  crucial  or  semilunar  incision  of  the  skin  over  the 
gland,  and  tie  and  cut  the  vessels  between  two  ligatures;  seize  the 
gland  with  a  hook,  draw  it 
out  and  isolate  it  from  the  hy- 
poglossal nerve  and  lingual 
artery  by  careful  dissection; 
apply  a  ligature  above  the 
])lace  where  the  gland  is  to  be 
severed  and  separate  it  from  its  ^;fi^ 
connections;  close  the  wound  ^^ 
accurately  with  sutures.^ 

III.  Tin-:  TONSILS. 
These  bodies  occupy  the 
recesses  between  the  anterior 
and  posterior  pillars  of  the 
fauces  and  are  about  six  lines 
in  leu'^th  and  four  in  width 
and  thickness. 

The  outer  side  is  connected 
with  the  inner  surface  of  the  su- 
perior constrictor  of  the  pharynx, 
lies  near  the  internal  carotid  ar- 
tery, and  corresponds  with  the  angle  of  the  lower  jaw  externally;  ■*  it  is  covered 
on  the  external  surface  by  a  fibrous  semi-capsule  which  facilitates  enucleation 
of  the  gland. ^    Tlie  instruments  required  for  operations  on  the  tonsils  are  as  fol- 

1  II.  Liston.  -  A.  Velpeau;  V.  Mott.  8  Bernard  and  Huette. 

*  Quains  Auat.  5  Chassaignac. 


Fig.  .330. 


366  OPERATIVE  SURGERY. 

lows  (Fig.  331)  :  (1)  tenaculum  forceps  for  seizing,  a,  or  forceps  with  curved 
serrated  surfaces,  6,- 1  (2)  tonsilotonie,  c,"^  or  e,-3  tonsil  scissors,  rf,  curved  on 
the  fiat. 

1.  Abscess  of  the  tonsils  must  be  punctiire<l  as  soon  as  pus  is 
detected,  care  being  taken  to  avoid  wounding  the  internal  carotid 
artery.  Select  a  broad  spatula  and  a  sharp-pointed,  straight  bis- 
toury, wrapped  to  within  aliout  half  an  inch  of  its  extremity;  place 
the  patient  in  a  chair  in  front  of  a  good  light,  the  head  firndy  sup- 
ported by  an  assistant;  lay  the  spatula  lightly  on  the  tongue  until 
the  abscess  is  brought  into  view;*  pass  the  knife  backwards,  avoid- 
ing wounding  the  tongue,  and  incline  the  point,  when  it  penetrates 
the  tonsil,  towards  the  iBedian  line  of  the  fauces,  thus  protecting  the 
internal  carotid  from  all  danger;  if  the  abscess  cannot  be  sufficiently 
exposed  it  may  be  necessary  to  direct  the  point  of  the  knife  by  the 
inde.x  finger  of  the  left  hand;  if  the  abscess  contain  a  large  amount 
of  pus  the  patient's  head  should  be  thrown  forward  immediately  after 
the  puncture  to  avoid  the  flow  into  the  pharynx  or  larynx. 

2.  Hypertrophy  of  the  tonsil  is  caused  by  repeated  acute  con- 
gestions of  the  pharyngeal  mucous  membrane,  and  consists  of  an 
equable  and  uniform  overgrowth  of  all  the  histological  elements  of 
the  follicles;  the  size  and  shape  of  the  entire  tonsil  undergoes  an 
alteration;  it  forms  a  globular  and  often  pedunculated  tumor  which 
may  j)roject  so  far  as  to  interfere  with  breathing.^  Removal  is  re- 
quired only  in  extreme  cases,  as  when  the  voice  is  seriously  affected, 
or  the  sleep  is  so  disturbed  as  to  impair  the  health,  or  the  secretions 
of  the  ducts  are  very  fetid.^  Excision  may  be  performed  with  curved 
hook-teeth  foi'ceps  (Fig.  330,  a,  b)  and  a  straight  probe-pointed  or 
curved  scissors  (Fig.  330,  </),  or  with  the  tonsilotonie  (Fig.  330,  c 
ore).  If  the  patient  is  a  child,  give  chloroform,  and  when  suffi- 
ciently under  its  influence  to  open  the  mouth,  seize  the  tonsil,  draw 
it  out  from  between  the  pillars,  and  having  the  knife-blade  wrapped 
to  within  an  inch  of  its  point,  cut  away  from  below  upward  the 
proper  amount;  if  an  adult,  place  him  in  a  chair  in  a  good  light  and 
incise  with  the  knife  or  the  tonsilotonie.  If  the  latter  is  used,  ad- 
just the  ring  to  the  gland  on  its  inner  and  lower  aspect,  with  the 
index  finger  ascertain  that  the  gland  is  embraced  by  the  ring;  with 
the  thumb  and  finger  of  the  same  hand  close  the  forceps,  draw  the 
gland  through  and  project  the  knife  with  the  thumb  of  the  right 
hand.  Or,  the  instrument  may  be  automatic  (Fig.  331),  requiring, 
when  once  ajiplied  to  the  tonsil,  only  the  closure  of  the  handles, 
both  to  seize,  draw  out,  and  excise  the  gland;  if  the  haemorrhage  is 
too  free,  use  ice  applications,  or  ice- water  gargle. 

1  Mnsoeux.  2  J.  s.  Billings.  3  p.  H.  Hamilton.  4  G.  Pollock. 

6  E.  Kiuddeisch. 


THE  TONGUE. 


367 


3.  Cancer,  rncephaloid,  may  appear  in  the  tonsil,  as  a  primary  (ir 
secondary  disease,  and  has  been  treated  by  extirpation  of  the  glnnd. 
Removal  by  external  incision  is  to  be  preferred,  for  excision  from 
within  is  liable  to  uncontrollable  hu.'morrliage  and  secondary  slough- 


in::;  tboutrh  the  external  operation  is 
danjicrous,  owing  to  the  depth  of  the 
wound,  the  proximity  of  the  internal 
carotid  artery  and  the  crossing  of  the  hy- 
poglossal, gustatory,  and  glosso-[)haryngeal 
nerves,  there  is  no  other  risk  than  the  liabil- 
ity to  pharyngeal  fistula.^  Amygdalotoiiiy 
requires  a  knife,  clawed,  dissecting,  and  ar- 
tery forceps,  and  ligatures;  the  shoulders 
being  raised  and  turned  to  the  opposite 
side,  make  an  incision  extending  from  just 
within  the  angle  of  the  jaw,  downwards, 
over  the  most  prominent  part  of  the  tumor, 
three  inches  and  a  half,  parallel  with  the 
sterno-masloid  muscle;  make  a  second  in- 
cision, meeting  this  along  the  lower  border 
of  the  jaw  one  and  a  half  inches;  dissect 
the  soft  parts  until  the  diseased  growth  is 

reached,  dividing  the  stylo-hyoid  and  stylo  glossus  muscles  and  sep- 
arating the  fillies  of  the  superior  constrictor  of  the  pharynx;  arteries 
cut,  as  the  facial,  nmst  be  promptly  ligated ;  the  gland  must  now  be 
enucleated  and  separated  from  surrounding  fiarts;  close  the  horizon- 
tal wound  with  a  suture,  but  leave  the  other  open;  lifjuid  nourishment 
should  be  administered  by  the  stomach-pump  until  the  wound  is 
sufficiently  closed.^ 


Fig.  331.2 


CHAPTER   XXXIII. 


THE    TONGUE. 

The  tongue  is  a  muscular  organ  covered  with  mucous  membrane; 
posteriorly  it  is  connected  with  the  hyoid  bone;  inferiorly  it  receives, 
from  base  to  apex,  the  fibres  of  the  genio-glossus  muscle,  bv  which 
it  is  attached  to  the  lower  jaw;  the  ranine  arteries  run  along  the 
lower  surface  from  base  to  apex.^ 

1  D.  W.  Cheever.  2  Tiemaun  &  Co.  8  Quain's  Anatomy. 


368 


OPERATIVE  SURGERY. 


The  only  special  instruments  required  for  operations  on.  the  tongue  are  the 
^craseur,  and  the  galvano-cautery.  The  ecraseur  i  (Fig.  332)  is  especially 
adapted'-^  to  the  removal  of  diseased  structures  in  highly  vascular 
tissues,  as  in  the  removal  of  malignant  disease  of  the  tongue, 
haemorrhoids,  cancerous  affections  of  the  anus,  uterine  polypi; 
of  the  various  modifications  none  are  equal  in  practice  to  tiie 
original  instrument;  the  resistance  encountered  in  tightening  it 
proves  tiie  density  of  tissue;  every  click  measures  accurately 
the  progress  of  the  chain,  and  it  finally  cuts  neatly  through 
without  throwing  out  long  shreds  of  tissue,  leaving  the  operator 
in  doubt  wlien  the  tumor  is  entirely  severed,  if  it  is  hidden  from 
view;  the  ditficidty  of  carrying  the  chain  around  the  tumor  when 
the  latter  is  situated  in  the  vagina  or  uterus,  has  been  the  only 
obstacle  to  its  use;  this  defect  is  now  supplied  bj-  the  porte- 
chaine,  added  to  the  original  instrument,  which  consists  of  a 
pair  of  dilating  forceps  with  spring  blades,  which  render  the 
chain  tense,  so  that  it  may  be  passed  straight  into  the  vagina  or 
into  the  cavity  of  the  uterus  as  easily  as  a  sound,  after  which 
the  chain  is  expanded  by  the  blades  of  the  porte-chaine.  Gal- 
vano-cautery is  cauterization  b_v  a  resisting  wire  heated  by  the 
galvanic  current;  this  effect  is  in  accordance  with  the  law  of 
biG.  66Z.  electricity,  that  when  it  passes  through  a  resisting  wire  it  raises 
the  temperature  in  proportion  to  the  resistance  of  the  wire  and  the  quantity 
of  electricitv,  and  the  wire  thus  heated  is  capable  of  producing  cauterizing  ef- 
fects; as  platinum  offers  the  greatest  resistance  to  the  current  it  is  preferred. 
A  universal  electrode  for  galvanic  cautery  operation  is  now  provided ^  (F'g- 
333),  which  combines   strength,   lightness,  durability,  and   perfect   reliability, 


Fig.  333. 

whether  used  as  a  galvanic  cautery,  ccraseur,  or  cautery  knife,  needle,  or  appli- 
cator: ^4  is  a  solid  hard  rubber  handle  through  which  pass  the  conducting  rods 
C  C,  connected  with  the  battery  wires  at  B ;  the  rods  at  C  C  being  hollow  half 
their  length  admit  of  the  rods  running  from  the  ivor}'  tip  E  to  slide  in  and  out 
like  a  telescope,  which  they  are  made  to  do  by  turning  the  small  wheel  F ;  this 
telescoping  of  the  rods  keeps  up  perfect  current  connections  and  at  the  same  time 
causes  a  slow  contraction  of  the  wire  cautery  loops  at  E,  the  ends  of  the  wire 
being  secured  in  the  ivory  clamp  G  in  the  rods  C  C ;  the  current  is  regulated, 
or  cut  off  and  on,  from  the  battery  by  the  screw  D ;  three  other  cautery  instru- 
ments of  different  forms  may  be  adjusted  to  the  handle,  which  are  used  by 
withdrawing  the  tip  E  with  its  rods,  and  adjusting  the  individual  cautery,  that 
maj'  be  requisite,  with  open  ends  of  the  rods  CC ;  the  battery  (Fig.  334)  is  com- 
posed of  but  two  cells,  in  each  of  which  are  two  positive  (zinc)  and  one  negative 
(platinum)  plate,  all  measuring  but  four  and  a  half  by  six  inches;  the  zincs  A, 


1  E.  Chassaifiuac. 


2  J.  M.  Sims. 


3  B.  F.  Dawson. 


THE    TONGCE. 


5C9 


Flu.  334.1 


are  perforated,  and  adjusted  but  half  an  inch  apart,  and  between  them  a  plat- 
inum plate  is  placed,  and  held  in  position  by  uprights  5 ;  on  each  side  of  the 
platinum  plates  are  hard 
rubber  or  ct-lliiloid  pumps 
or  agitators,  C,  worked  by 
means  of  a  small  knob; 
D  and  E  are  the  con- 
necting screws,  and  F  a 
knob  for  lifting  the  bat- 
tery out  of  the  cells;  the 
battery  requires  but  two 
and  a  half  pints  of  fluid, 
with  which  amount  it  will 
keep  up  a  most  powerful 
action,  I'liig  enough  tor 
the  most  prolonged  opera- 
tion, by  the  moving  up 
and  down  of  the  puinp<, 
C,  which,  according  to  the 
intensity  of  the  heat  de- 
sired are  mnved  more  or 
less  quickly;  by  this  ac- 
tion, the  old  and  ex- 
hausted fluid  betw^cen  thu 
plates      is      thrown     out 

through  the  perforations,  and  fresh  fluid  is  made  to  take  its  place,  thus  keeping 
up  a  uniform  power. 

The  galvano-cautery  is  especially  adapted  for  the  removal  of  tu- 
mors that  are  not  readily  accessible  by  other  means,  and  vascular 
growths  that  would  be  attended  with  severe  haemorrhage;  its  ad- 
vantage in  the  removal  of  the  tongue  are,  therefore,  that  (1)  it 
saves  all  haemorrhage;  (2)  it  combines  the  after-cauterizing  effects 
with  the  other  results  of  the  operation,  sometimes  desirable;  (3)  it 
is  but  little  painful  after  the  operation  and  is  never  dangerous;  its 
disadvanta.:es  are  the  difficulty  of  obtaining  and  managing  the  neces- 
sary apparatus, 

1.  Tongue-tie  is  a  congenital  malformation  in  which  the  fra?num- 
linguae  extends  too  far  forwards  towards  the  point  of  the  tongue, 
and  remains  rather  below  its  natural  height,  measured  from  the 
floor  of  the  mouth;  protrusion  is  hindered,  and  where  the  defect  is 
great  the  tongue  cannot  be  applied  against  the  roof  of  the  mouth; 
the  slight  form  is  harmless,  but  the  severe  form  presents  a  great 
obstacle  to  sucking;  in  the  latter  case  it  is  advisable  to  operate.* 
Division  has  been  followed  by  fatal  haemonhaire  from  the  ranine 
arteries; 3  l,ut  carefully  perfonned  it  is  without  danger  and  painless; 
pass'^  the  first  and  second  fingers  of  the  left  hand,  palm  downwards, 
under  the  tip  of   the  tongue    on   either  side  of  the   fra-num,  and 

1  G.  Tiemann  &  Co.  2  j.  Holmes.  3  f.  H.  Hamilton. 

24 


370  OPERATIVE  SURGERY. 

put  it  well  on  the  stretch  ;  snip  the  edge  of  the  frasnum  with  blunt- 
pointed  scissors  below  the  fingers,  thus  escaj)ing  the  ranine  arteries 
which  run  along  the  lower  surface  of  the  tongue;  push  the  tongue 
upwards  against  the  roof  of  the  mouth,  and  divide  further,  if  nec- 
essary ;  this  method  is  ])referable  to  the  use  of  the  cleft  in  the  handle 
of  the  ordinary  director. 

2.  Wounds  of  the  tongue  are  liable  to  be  followed  by  hajmor- 
rhao"e ;  use  styptics,  ligature,  or  the  actual  cautery' ;  these  wounds 
unite  readily;  the  treatment  is  to  clean  the  wound  of  shreds,  and 
close  with  sutures  ;  if  the  wound  is  so  extensive  that  the  tongue  is 
partially  severed,  it  must  still  be  united  ;  if  the  tongue  has  a  tendency 
to  fall  backwards,  pass  a  ligature  through  the  tip  and  fasten  it  to  the 
teeth  or  externally.^ 

3.  Glossitis  is  generally  attended  by  a  sudden  swelling  or  oedema 
of  the  tongue,  threatening  suffocation.  The  remedy  is  free  and  deep 
lono-itiidinal  incisions ;  they  should  be  made  along  the  upper,  rather 
than  the  under  surface,  to  avoid  the  ranine  arteries  ;  when  one  side 
is  involved  the  oedema  may  be  so  great  as  to  cause  the  lower  surface, 
which  yields  the  more  readily,  to  be  turned  directly  upwards,  when 
the  incision  must  be  made  with  great  care.^ 

4.  Polypi  appear  on  the  under  surface  of  the  tongue,  as  elon- 
gated growths,  sensitive  to  the  touch  and  the  source  of  much  an- 
noyance ;  they  consist  of  a  stroma  of  connective  tissue,  infiltrated 
by  small,  round,  nucleated  cells,  and  covered  by  nearly  normal  epi- 
thelium. Excision  with  scissors,  and  injection  of  the  base  with  pure 
acetic  acid  with  the  hypodermic  syringe,  has  effectually  destroyed 
them.  3 

5.  Abscess  appears  as  a  firm  tumor,  imbedded  in  the  substance  of 
the  tongue,  after  acute  inflammation,  and  must  be  treated  by  in- 
cision. 

6.  Ranula  is  a  cyst  beneath  the  tongue,  but  intimately  related  to 
the  salivary  ducts.  The  ducts  becoming  closed,  the  epidermic  lining 
is  deposited  in  the  interior, 4  and  the  secretion  accumulates  until  a 
large  tumor  is  formed  which  presses  the  tongue  upwards  and  back- 
wards, greatly  interfering  witli  the  functions  of  that  organ.  These 
cysts  are  readily  recognized  on  inspection  of  the  under  surface  of  the 
tongue.  The  treatment  is  free  incision,  and  keeping  the  wound 
open;  if  this  fail,  excision  of  a  portion  of  the  walls  is  necessary;  if 
the  disease  persists,  open  the  cyst  and  cauterize  with  nitrate  of  sil- 
ver, or  even  nitric  acid.^  If  the  cyst  project  in  the  neck,  open  it  in 
the  middle  line  below  the  hyoid  bone,  and  keep  it  open  till  the  cavity 
is  obliterated. 

6.  Hypertrophy  is  usually  congenital,  and  may  be  noticed  imme- 
1  S.  D.  Gross.      2  H.  Coote.      3  s.  C.  Bussy.      ^  t.  Billroth.      »  T.  Holmes. 


THE   TONGUE. 


371 


Fig.  3y.3.'i 


diatfly  after  birth,  or  may  appear  later,  hv\\\%  uncertain  in  its  rate  of 
growth  ;  when  fully  developed  the  tongue  protrudes,  with  constant 
dribblinii  of  saliva,  and  causes  deformity  (Fi^.  33.'))  of  tin-  jaw.i 
The  treatment  by  pressure  and  asti'injrents  may 
first  be  attempted,  as  follows;  apply  <laily,  cupri 
sulph.  3j.  to  aq.  5  i-  on  lint,  and  conipiess  with 
a  bandage.-  If  these  means  fail,  removal  is  the 
only  alternative.  Excision  is  very  danirerons 
■when  the  ori^rjin  is  great,  owing  to  hajniorrhage  ; 
the  knife,  ligature,  ecraseur,  or  galvano-cautery 
may  be  employed ;  when  the  knife  is  used  the 
flaps  may  be  made  by  transfixing  the  tongue  lat- 
erally or  vertically ;  the  former  method  is,  in 
general,  preferable,  as  the  thickness  of  the  tongue 
is  thereby  much  more  reduced.^  The  head  being 
supported  against  the  breast  of  an  assistant,  who 
retracts  the  angles  of  the  mouth,  seize  the  tongue 
with  forceps  on  its  edges,  and  draw  it  well  forward ;  pass  a  strong 
ligature  transversely  through  the  back  part  of  the  tongue  with  which 
to  draw  the  organ  forward ;  transfix  the  tongue  frouj  side  to  siile  at 
the  point  where  excision  is  to  be  completed,  and  cut  forward  and 
downward,  through  its  under  surface,  making  the  lower  flap;  form 
the  upper  flaj)  by  cutting  in  a  reverse  direction,  backward  and  down- 
ward, to  the  point  where  the  first  section  had  commenced ;  ligate  the 
arteries  and  secure  the  flaps  in  contact  with  sutures ;  recovery  with 
a  flattened  tongue  and  good  speech  results.^  A  vertical  incision  may 
be  required,  in  order  to  remove  a  V-shaped  portion  of  sufficient  size, 
and  bring  together  the  lateral  flaps  so  as  to  form  a  new  tip,  which 
shall  fall  within  the  teeth  ;  the  patient,  anajsthetized,  being  placed 
with  the  head  elevated  and  held  by  an  assistant,  pass  the  knife 
through  the  substance  of  the  tongue  external  to  the  middle  line,  to 
avoid  the  ranine  artery,  cut  out  a  flaj),  and  tie  all  the  bleeding  vessels; 
pass  a  strong  ligature  through  this  flap  to  prevent  the  tongue  falling 
back;  enter  the  knife  at  the  same  point;  carry  it  across  the  middle 
lines,  dividing  the  ranine  arteries,  which  must  be  tied  before  the 
flap  is  finally  separated  ;  close  the  wound  with  strong  sutures  thus  : 
introduce  these  sutures  into  the  lateral  flaps  (Fig.  330),  and  on  tying 
them  the  tip  of  the  tongue  assumes  a  natural  appearance  (Fig.  337). 
Removal  by  the  ecraseur  involves  less  immediate  risk  from  haemor- 
rhage, but  is  liable  to  be  followed  by  dangerous  inflammatory  swelling. 
If  employed,  proceed  thus:  pass  the  chain  of  a  very  stout  instru- 
ment through  the  substance  of  the  tongue,  at  the  same  point  as  in 
excision  by  the  knife,  and  when  it  lias  worked  its  way  outwards  a 
1  T.  Holmes.  2  j.  Syme.  8  G.  Buck. 


372 


OPERATIVE  SURGERY. 


little,  pass  a  second  chain  and  work  it  at  the  same  time  towards  the 
opposite  side.i 

7.  Cancer,  in  the  form  of  squamous  epithelioma,  has  a  favorite 
seat  in  the  tongue;  the  primary  nodule  is  nearly  always  situated  on 
one  or  other  side  of  the  organ,  and  is  distinguished  by  its  softness  and 
tendency  to  seedy  disintegration  ;  on  removal,  it  returns,  and  the  in- 
terval between  removal  and  return  grows  shorter  each  time  until  the 


Fig.  336. 


Fig.  337. 


entire  tongue  is  destroyed.^  Scirrhus  commences  as  a  firm  incom- 
pressible knob  on  the  edge  of  the  organ,  often  opposite  the  last  molar 
tooth,  or  so  far  towards  the  root  as  to  be  beyond  reach  ;  the  symptoms 
are,  soreness,  painful  deglutition,  salivation,  pain  in  the  course  of  the 
Eustachian  tube,  ulceration,  hjemorrhage,  infiUration,  of  absorbent 
glands.^  Excision  of  the  diseased  part  or  extirpation  of  the  entire 
tono-ue  are  the  operations  recommended.  The  motive  to  operate 
here  is  not  greatly  to  prolong  life,  yet  enough  is  gained  to  justify 
an  operation  which  is  attended  with  very  little  suffering  or  risk,  but 
rather  to  secure  future  comfort,  which  in  many  cases  is  so  great  as  to 
justify  a  greater  risk  of  life  than  is  incurred  in  any  of  the  ordinary 
operations  for  the  removal  of  cancer  of  the  tongue  ;  though  the  dis- 
ease return  after  the  operation,  it  is  unreasonable  to  refuse,  on  that 
account,  a  painless  operation,  and  one  free  from  risk  to  life;  if  the 
patient  has  but  two  or  three  years  to  live,  it  is  no  small  advantage  if 
at  least  half  the  time  can  be  spent  in  comfort,  rather  than  in  misery; 
in  profitable  work,  rather  than  in  painful  idleness.*  Removal  of  a 
portion  of  the  tongue  may  be  performed  with  the  knife,  the  ecraseur, 
the  ligature,  or  the  galvano-cautery :  the  knife  is  preferable  to  the 
ecraseur  in  all  but  the  largest  operations;  tlie  ligature  is  rarely  re- 
quired, and  the  caustic  is  to  be  used  only  where  the  disease  is  limited.'* 
In  the  removal  of  the  tongue  for  cancer,  by  the  knife,  the  ligature 
of  the  lingual  artery  near  its  origin  has  proved  an  important  prelim- 
inary step,  as  it  is  less  difliicult  than  securing  the  vessels  in  the  wound 
1  T.  Holmes.  2  e.  Rindfleisch.  3  H.  Coote.  *  Sir  J.  Paget. 


THE   TONGUE. 


373 


during  the  operation,  controls  all  liaemorrhage,  and  may  have  a  ten- 
dency to  retard  the  return  of  the  disease.^ 

In  operating  with  the  knife  select  a  straight  blade,  or  use  scissors 
with  serrated  edges,  and  stout  hooked  forceps;  place  the  patient 
in  a  chair,  without  aniesthetic,  if  consent  is  obtained,  the  head  sup- 
ported, and  the  tip  of  the  tongue  held  by  the  fingers  of  an  assistant, 
either  with  the  aid  of  a  towel,  forceps,  or  ligature  passeil  through  if, 
seize  the  tumor  completely  within  the  blades  of  a  donble-hooked  for- 
ceps, and  with  the  kiiifi'  swcij)  away  tlie  entire  diseased  mass,  tie 
any  bleeding  artery,  and  control  ha'uiorrhage  with  ice;  use  no  other 
ligatures,  nor  sutures,  to  avoid  irritation,  but  allow  the  wound  to  heal 
by  granulation.'^  The  ecraseur  may  be  used  when  the  excision  in- 
volves one  or  both  ranine  arteries;  pass  the  chain  around  the  mass 
(Fig.  338),  or  through  the  centre  of 
the  tongue,  tighten  it  by  one  turn 
every  two  minutes  luitil  it  divides 
both  sections.  The  amount  of  tongue 
that  can  be  removed  throngh  the 
mouth  l>y  these  means  is  measured 
only  by  the  appliances  the  surgeon 
has  at  his  connnand  to  fix  its  poste- 
rior boundary. 3  By  dividing  all  the 
muscles  uniting  the  jaw  and  hyoid 
bone  on  both  sides,  as  near  the  jaw 
as  possible,  the  tongue  may  be  drawn  F'*^-  '"^"^S- 

almost  entirely  out.*  Galvano-cautery  may  be  used  either  (1)  by 
drawing  the  tongue  forcibly  forwards  and  then  passing  stout  pins 
through  it,  behind  which  the  wire  is  placed  and  maintained  in  posi- 
tion; or  (2)  the  double  wire  may  be  passed  through  the  centre  of  the 
tongue  by  means  of  a  strong  curved  needle  and  the  needle  being  cut 
away,  the  ends  of  the  wire  on  one  side  are  attached  to  the  electrode, 
and  the  division  made,  and  then  the  other  side  is  removed  in  the 
same  manner;  the  wire  should  not  be  heated  iibove  a  dull  red  heat. 

Extirpation  of  the  entire  tongue  by  the  kinfe  is  most  effectually 
performed  as  follows:  Seat  the  patient  on  a  chair,  without  an  anaes- 
thetic; extract  one  of  the  front  incisors,  and  make  an  incision 
through  the  middle  of  the  lip  down  to  the  hyoid  bone;  saw  through 
the  jaw  in  the  same  line;  now  pass  the  finger  under  the  tongue  and 
divide  mucous  lining  of  the  mouth  with  the  attachments  of  the  genio- 
hyo-glossis;  while  the  two  halves  of  the  jaw  are  held  apart,  dissect 
backwards,  cutting  through  the  hyo-glossis  along  with  the  mucous 
membrane  covering  them,  so  as  to  allow  the  tongue  to  be  pulled  for- 
wards,  and  bring  into  view   the  situation   of   the  lingual  arteries, 

1  G.  F.  Shrady.  ^  h.  Coote.  »  T.  Bryant.  ^  Sir  J.  Paj,'et. 


374  OPERATIVE  SURGERY. 

which  must  be  tied  on  both  sides ;  now  cut  away  the  tongue  from  its 
attachment  to  the  bone,  protecting  the  knife  with  the  finger  passed 
over  to  the  os  hyoides;  Ugate  arterial  twigs  and  close  the  wound.^ 
The  tongue  may  be  extirpated  by  opening  the  mouth  by  a  semi-lunar 
submental  incision  and  thoroughly  detaching  the  muscles  and  other 
soft  structures  from  the  bone,  and,  when  necessary,  making  also  a 
vertical  incision  down  to  the  h}oid  bone.^ 

The  ecraseur  may  be  employed  with  the  common  wire  rope,  or 
with  the  galvano-caustic.  The  former  has  been  used  very  success- 
fully, as  follows:  select  a  sharp-pointed,  curved  blade,  about  four 
inches  long,  and  of  sufficient  thickness  and  breadth  to  carry  the  wire 
rope  of  the  dcraseur ;  the  rope  should  be  sufficiently  stout,  and  the 
middle  attached  by  a  piece  of  string  to  an  eye  made  in  the  broad 
end  of  the  blade  ;  cauterizing  irons  and  the  solid  perchloride  should 
be  at  hand  ;  place  the  patient  in  a  semi-recumbent  position  without 
anaesthetic,  and  enter  the  knife  in  the  median  line  between  the  base 
of  the  jaw  and  the  hyoid  bone,  but  nearer  the  latter,  and  carry  it 
into  the  mouth  at  the  fraenum  linguae,  with  the  loop  of  wire;  draw  a 
good-sized  loop  through,  and  cut  off  the  needle  ;  pass  the  loop  over 
the  base  of  the  tongue,  which  should  be  drawn  forcibly  forward  by 
forceps  ;  pass  two  or  three  long  and  strong  hare-lip  pins,  slightly 
curved  at  the  points,  from  the  under  side  of  the  anterior  attachment 
of  the  tongue,  one  on  each  side  and  the  third  in  the  middle,  through 
its  substance  and  on  its  upper  surface  as  near  to  its  base  as  possible; 
their  points  should  just  appear  on  the  upper  surface  to  prevent  the 
slipping  of  the  wire,  but  they  are  not  absolutely  necessary  ;  tighten 
the  wire  slightly,  and  give  an  anaesthetic;  now  slowly  turn  the  screw 
of  the  Ecraseur  while  the  tongue  is  forcibly  extended ;  more  force  is 
often  required  than  was  anticipated,  but  the  wire  must  not  cut 
through  too  rapidly  ;  if  there  is  too  much  haemorrhage,  which  is  very 
rare,  tie  any  bleeding  vessel,  or  apply  the  cautery ;  the  after  treat- 
ment consists  in  allaying  inflammation  of  the  part  by  pieces  of  ice, 
giving  nutritious  and  opiate  enemata ;  keeping  the  injured  parts  at 
rest;  the  submental  wound  heals  by  first  intention,  the  local  inflam- 
mation rapidly  subsides,  and  the  patient  is  soon  able  to  swallow.^ 
The  submental  incision  may  be  avoided  by  forcibly  withdi'awing  the 
tongue  and  dividing  the  attachments  to  the  jaw,  both  in  front  where 
the  genio-hyo-glossi  muscles  are  insei'ted,  and  at  the  sides  where  it 
is  connected  with  the  mucous  membrane.'*  The  sublingual  tissues 
may  be  divided  by  the  ecraseur  itself,  additional  space  being  gained 
by  incising  the  cheek  below  the  angle  of  the  mouth.^ 

Excision  of  half  of  the  tongue,  a  part  of  each  jaw,  submaxillary 

1  J.  Syme.  2  e.  B.  Regnoli;  S.  D.  Gross.  3  Nunneley. 

4  Sir  J.  Paget.  5  M.  Collis. 


THE  PHARYNX. 


375 


glands,  and  side  of  pharynx,  have  been  successfully  performed;  the 
patient  bein<^  under  an  anaesthetic,  an  incision  was  made  from  the 
angle  of  the  mouth  to  the  sut)maxillary  reiiion  of  the  left  side; 
the  facial  and  liii<;ual  arteries  and  veins  were  tied  ;  the  upper  jaw 
clipped  with  forceps  at  the  posterior  and  lower  corners;  the  lower 
jaw  was  sawn  through  at  the  canine  tooth  and  immediately  above 
the  angle,  the  tongue  drawn  out  and  transfixed  with  a  sharp-|)ointed, 
curved  bistoury,  from  the  middle  line  at  the  hyoid  bone  to  the  base 
of  the  epiglottis,  and  then  slit  to  the  tip ;  part  of  the  soft  palate  and 
side  of  the  pharynx  were  then  separated  with  the  rest;  a  pharyngeal 
fistula  remained  eighteen  months  after  the  operation.* 


CHAPTER    XXXI V. 

THE   rilARYNX  ;    THE   (ESOPHAGUS. 


Fig.  .339. 


I.     TllK    PHARYNX. 

The  pharynx  unites   the   cavities  of   the  mouth  and  nose  to  the 
oesophagus,  ami  extends  from  the  base  of  the  skull  to  the  lower  bor- 
der of  the  cricoid  carti-  /f^^ 
lage,  forming  a  sac  open  W^  \.  ■ 
at   the   lower    end    anil  V*:    \ 
imperfect  in  front,  where 
it      presents     apertures 
leading   into    the    nose, 
mouth,  and  larynx.- 

1.  Inspection  of  the 
pharynx  is  so  imperfectly  made  in  the  ordinary  way  with  the  com- 
mon spatula  or  a  spoon- 
handle,  that  it  is  im- 
portant to  be  always 
provided  with  a  suit- 
able mirror,  or  reflector, 
which  enables  the  oper- 
ator to  expose  the  cav- 
ity of  the  pharynx  in 
the  same  manner  as  the 
larynx.  For  this  pur- 
pose a  simple  pocket- 
mirror  (Fig.  o3J))  may 
be  provided  which  both 
illuminates  the  pharynx 
1  R.  Paiker.  2  Quain's  Anatomy. 


Fig.  340. 


37G  OPERATIVE  SURGERY. 

by  the  mirror,  5,  and  reflects  the  surface  by  the  second  mirror,  a  ^ 
For  thorough  examination  of  the  pharynx  a  tongue  depressor  is  also 
required  (Fig.  340).^ 

2.  Wounds  may  be  incised  or  punctured,  and  are  liable  to  serious 
complications  from  the  depth  of  the  tube  and  the  important  parts 
which  surround  it ;  if  the  wound  is  free,  ingesta  will  escape  exter- 
nally; if  no.t,  abscesses  and  sinuses  are  liable  to  form.^  Longitudinal 
wounds  require  no  other  treatment  than  approximation  by  adhesive 
plaster,  but  transverse  wounds  should  be  closed  if  possible,  by  suture, 
while  the  external  wound  is  left  open.^  If  the  pharynx  is  nearly  or 
quite  severed,  the  wound  will  be  opened  and  food  escape  at  every 
effort  of  deglutition;  to  avoid  this  complication,  a  tube,  as  a  catheter, 
or  that  of  a  stomach  pump,  must  be  regularly  passed  down  below 
the  wound,  and  nourishing  fluids  injected  into  the  stomach.* 

3.  Abscess  may  form  posterior  to  the  pharynx,  in  front  of  the 
cervical  vertebra,  in  the  submucous  cellular  tissue;  it  often  appears 

in  connection  with  caries  of  the  vertebras  and 
disease  of  the  lymphatic  glands,  is  very  insidious 
in  its  invasion,  and  tardy  in  its  progress  ;  slight 
diflSculty  of  deglutition  and  breathing,  with  an 
inclination  to  snore,  are  often  the  first  noticeable 
symptoms.  On  inspection,  if  the  mouth  can  be 
opened  sufficiently,  a  tumor  is  seen,  of  a  reddish, 
livid,  or  purple  color,  bulging  forward  into  the 
fauces,  irregular  in  form  ;  if  examined  with  the 
finger,  it  will  have  a  distinct  sense  of  fluctuation 
on  pressure  ;  or  the  abscess  may  be  acute,  at- 
tended with  deep-seated  pain,  great  swelling, 
dysphagia  and  dyspnjea,  and  severe  constitu- 
tional disturbance.^  These  abscesses  should  be 
Fig.  .341.6  opened  at  an  early  period  by  puncture  through 

the  mouth,  either  with  a  long,  straight,  narrow-bladed  knife,  having 
all  of  its  blade  protected  except  half  an  inch  of  its  pointed  extremity, 
by  a  pharyngeotome  or,  when  it  is  very  large,  by  aspiration ;  care 
should  always  be  taken  to  prevent  the  contents  of  a  large  abscess 
from  suddenly  discharging  into  the  larynx. 

4.  Foreign  bodies,  if  thin  and  pointed,  as  pins,  needles,  fish- 
bones, bristles,  most  frequently  stick  between  one  or  other  of  the 
pillars  of  the  fauces  and  the  tonsil,  or  in  the  mucous  folds  connecting 
the  base  of  the  tongue  with  the  epiglottis;  if  more  bulky,  they  are 
arrested  at  or  about  the  junction  of  the  pharynx  and  the  oesophagus. 
The  symptoms  of  a  small  pointed  body  in  any  of  these  positions  are 

1  L.  Elsberg.  2  L.  Elsberg;  \V.  H.  Church.  3  Q.  H.  B.  Macleod. 

*  A.  E.  Durham.       8  s.  D.  Gross.  6  G.  Tiemanu  &  Co. 


THE  (ESOPHAGUS. 


377 


H 


local  pain,  with  a  pricking,  increased  on  pressure  behind  the  angle 
of  the  jaw;  sometimes  there  is  difHcuhy  or  pain  in  swallowino',  with 
a  disposition  to  vomit;  when  it  is  at  the  upper  orifice  of  the  larvnx 
there  may  be  cough  and  dyspnaia  ;  if  the  body  is  Large  it  usually 
causes  death. ^  In  every  case,  instead  of  wiping  the  parts  roughly 
with  a  sponge,  make  the  most  careful  attempts  to  discover  and  re- 
move the  boily;  if  it  is  small,  and  not  detected  hy  the  sight  or  finorer, 
use  a  laryngeal  mirror  requiring  the  patient  to  inspire  flfcplv  while 
the  tongue  is  depressed;  when  found,  seize  it  with  properly  eiirved 
forceps  (Fig.  341).^  Or,  eniploy  the 
bristle  probaiig  (Fig.  342),  wliicli 
must  be  introduced,  closed,  below 
the  foreign  body,  then  spread  out 
and  slowly  withdrawn.  If  the  ob- 
structing body  is  food,  dislodge  it 
with  the  finger,  or  by  inverting  the 
trunk,  as  of  a  child,  and  giving  to 
the  back  in  that  region  a  smart  blow. 
or  by  forcing  it  downward  with  a 
probang  (Fig.  343).     If  asphyxia  is     j  k 

threatened,  perform  tracheotomy  or  li<;-  343. 
laryngotomy.  If  the  body  is  irregular,  and  too 
firmly  impacted  to  be  removed  without  danger- 
ous violence,  open  the  j)harynx,  even  though 
Fig.  .342.3  severe  symptoms  are  present.^    Pharyngotomy 

and  oesophagotomy  have  the  same  details. 


6 


II.     THE  (ESOPHAGUS. 

The  cesnphafrus  commences  at  the  cricoid  cartilage  opposite  the 
lower  border  of  the  fifth  cervical  vertebrae,  dej^cends  along  the  front 
of  the  spine,  passes  through  the  diaj)hragm  opposite  the  idnth  dorsal 
vertebrte,  where  it  ends  in  the  cardiac  orifice  of  the  stomach;  its 
length  is  nine  or  ten  inches. 

Its  narrowest  part  is  at  the  commencement,  and  it  is  slightly  constricted  at 
the  (lia|>hraijru ;  it  has  an  anlero-posterior  flexure  corresponding  witii  tiie  ver- 
tebral ciiliimn,  and  two  lateral  curves  to  the  left,  one  just  below  its  commence- 
ment and  the  second  near  its  termination;  in  the  neck  it  is  nearer  the  left  than 
the  right  side,  lies  close  behind  the  trachea,  and  the  recurrent  laryngeal  nerves 
ascend  in  the  angles  between  them;  on  each  side  is  the  common  carotid  artery, 
the  left  being  in  more  immediate  connection.* 

1.  Medication  through  the  a?sophagus  by  instruments  may  be  ef- 
fected liy  entering  the  tube  at  the  mouth,  or  the  nostril.      Cathetir- 


1  A.  E.  Durham. 
*  Tiemanu  &  Co. 


2  E.  Arnolt;  E.  Cock;  D.  W.  Cheever. 
■*  t^uain's  .-Vnatom^'. 


378 


OPERATIVE  SURGERY. 


Fig.  344. 


ism  of  the  oesophagus  requires  a  tube  aljout  thirty  inches  long  (Fio-s. 
350,  351),  and  the  stomach  pump.  Place  the  patient  in  a  chair, 
the  head  thrown  back,  and  supported  by  an  assistant;  if  the  tube  is 
passed  by  the  mouth,  depress  the  tongue  with  the  left  index  finger, 
or  a  spatula;  with  the  fingers  of  the  right  hand  take  the  tube,  well 
oiled  and  curved,  as  a  pen,  the  concavity  forward,  and  pass  it  gently 
along  the  posterior  wall  of  the  pharynx  and  oesophagus  to  the  stom- 
ach, the  head  being  thrown  slightly  for- 
ward as  the  tube  descends;  if  the  tube 
is  passed  by  the  nostril  the  patient  should 
take  the  same  position,  and  the  surgeon 
should  manipulate  the  tube  as  before, 
taking  care  to  pass  it  cautiously  along 
the  floor  of  the  nostril  (Fig.  344)  and 
the  posterior  wall  of  the  pharynx;  if  the 
tube  enter  the  larynx,  violent  symptoms, 
as  cough  and  suffocation,  are  excited. 
2.  Foreign  bodies  are  most  liable  to  lodge  opposite  the  cricoid 
cartilage,  or  just  above  the  diaphragm,  where  the  tube  is  most  con- 
stricted; if  small  in  bulk,  but  pointed,  as  a  needle,  it  may  stick  in 
the  mucous  membrane  a 
long  time,  or  loosen  easily 
by  ulceration,  or  penetrate 
the  walls;  if  large,  hard, 
and  irregular,  deglutition  is 
generally  difficult,  and  serious  results  are 
early  threatened ;  the  diagnosis  depends  upon 
the  history,  and  an  examination  by  the  hand.^ 
The  treatment  consists  in  promj)t  removal; 
if  the  substance  is  digestible,  endeavor  to  force  it 
onward  into  the  stomach  by  the  prcjbang;  if  indi- 
gestible, attempt  to  withdraw  it  by  means  of  for- 
ceps, having  a  suitable  curve  (Figs.  345,  346,  347). 
Introduce  them,  well  oiled,  with   the  blades  closed,  Fig.  345.2 

using  them  as  a  probe,  until  the  object  is  reached,  when   they  should 
be  opened  and  an  attempt  be  made  to  seize  the  foreign  body  ;  if 


Fig.  .346.2 

"uccessful,  tlu!  most  careful  manipulation  is  necessary  in  withdraw- 
ing it  to  avoid  lacerating  the  mucous  membrane;  if  the  Ijody  is  small, 
1  G  Pollock.  2  G.  Tiemann  &  Co. 


THE   (ESOPnAGUS.  379 

use  a  probang,  to  wliidi  a  dry  sponge  is  fastened,  or  a  sound,  to 
which  a  t;keiii  of  silk  is  attached,  so  as  to  form  a  snare  with  a  great 
number  of  loops,  or  the  bristle  probang  (Fig.  342);  these  instru- 
ments should  be  passed  beyond  the  obstruction  and  gently  rotated 


Fig.  347. 

during  its  withdrawal;  coins  and  siicli  bodies  may  often  be  extracted 
with  a  flat  blunt  book  connected  by  a  tbin  slip  of  steel  to  the  end 
of  a  long  whalebone  probang  (Fig.  348);   vomiting  induced  by  titil- 

^,^.^  lating  the  fauces,  or  injecting  apo- 
^^  morphia  into  the  arm,  will  sometimes 
dislodge  a  small  body,  but  if  the 
obstruction  is  firm,  excessive  vomiting  may  fix  it  more  firudy, 
or  rupture  the  oesophagus;  if  respiration  is  dangerously  em- 
barrassed, tracheotomy  must  be  performed,  and  if  the  ob- 
Fig!^348.  struction  is  below  the  point  of  operation,  a  tube  must  be  car- 
ried down  the  trachea  sufficiently  to  admit  the  air  to  the 
lungs.  When,  however,  a  solid  substance,  though  only  of  moderate 
size  and  irregtdar  shape,  has  become  fixed  at  the  commencement  of 
the  oL'sopliagus,  or  low  down  in  the  jiharynx,  and  has  resisted  a  fair 
trial  for  its  extraction  or  displacement,  its  removal  should  at  once  be 
effected  by  incision  into  that  tube,  though  no  urgent  symj)toms  are 
present. 

3.  Stricture  of  the  oesophagus  is  spasmodic  or  organic;  the 
former  occurs  in  hysterical  persons,  is  intermittent,  easily  overcome 
by  the  probang,  and  disajjpears  altogether  under  anjesthesia.  Con- 
tractions resulting  from  cicatricial  tissues  or  cancerous  growth,  occur 
chiefly  on  a  level  with  the  cricoid  cartilage  or  the  bifurcation  of  the 
trachea.*  The  leading  symptom  of  organic  stricture  is  gradually  in- 
creasing difficulty  of  deglutition,  with  its  concomitant  distress  and 
pain;  if  the  patient  is  tbin  and  the  stricture  high,  it  may  sometimes 
be  felt  externally;  to  determine  its  presence  and  peculiarities,  place 
the  patient  in  a  sitting  posture,  with  the  head  thrown  l)ack,  and 
pass  an  olive-pointed  (esophageal  bougie  along  the  posterior  wall  of 
the  pharynx  down  the  tube  to  the  seat  of  obstruction ;  the  extent 
and  condition  of  the  stricture  can  now  be  made  out.  The  cause 
may  be  an  injury,  syphilis,  or  cancer;  the  diagnosis  in  the  early 
period  depends  upon  the  history;  later,  simple  stricture  is  attended 

1  J.  Orth. 


380  OPERATIVE   SURGERY. 

•nith  the  discharge  of  a  large  amount  of  glairy  mucus,  and  cancerous 
structure,  with  the  escape  of  pus,  blood,  and  shreds  of  tissue.^  The 
treatment  of  the  cicatricial  form  is  by  dilatation,  and  the  cancerous 
on  the  expectant  plan,  or  by  gastrostomy. ^  Dilatation  requires 
assorted  rubber  dilators  ;  ^  place  the  patient  in  a  chair,  with  the 
head  thrown  back;  depress  the  tongue  with  the  finger  or  a  spatula, 
and  holding  the  bougie  as  a  pen,  pass  it  along  the  posterior  wall  of 
the  pharynx  down  to  the  obstruction,  and  genth-  insinuate  the  con- 
ical extremity  into  the  contracted  passage  ;  the  force  used  should  be 
slight,  the  object  being  to  open  the  stricture  laterally  and  not  push  it 
downward;  repeat  the  operation  every  second  or  third  day,  fj-adu- 
ally  increasing  the  size  of  the  bougie  as  the  stricture  is  enlarged; 
dilators  containing  air  or  water  are  more  gentle  and  uniform  in  the 
pressure,  but  difficult  and  uncertain  in  management;^  if  the  stric- 
ture is  unyielding  and  deglutition  becomes  impossible,  oesophagotoniy 
may  be  performed  below  the  stricture  with  a  view  to  the  introduc- 
tion of  nourishment  into  the  stomach  ^  by  means  of  a  suitable  tube. 
4.  CBsophagotomy.  1,  2,  3,  4  (Fig.  349),  is  neither  difficult  of  execu- 
tion, nor  necessarily  accompanied  with  great  risk, 
and  has  proved  eminently  successful,  when  early 
performed,  for  the  removal  of  foreign  bodies*; 
place  the  patient,  fully  anfesthciized,  on  the  back, 
the  head  and  shoulders  sligbtly  elevated,  and  face 
turned  to  the  opposite  side;  if  the  foreign  body 
project,  make  the  operation  at  that  point;  if  not, 
operate  on  the  left  side  to  which  the  oesophagus 
inclines:  make  an  incision  in  the  course  of  the 
depression  between  the  sterno-mastoid  and  the 
trachea,  extending  from  about  opposite  the  upper 
border  of  the  thyroid  cartilage,  nearly  to  the  sterno-clavicular  artic- 
ulation, through  the  integument;  divide  the  platysma  myoides  muscle 
and  the  cervical  fascia;  separate  the  edges  of  the  wound  and  draw 
the  omo-hyoid  muscle  outward  or  cut  it;  divide  the  outermost  fibres  of 
the  sterno-hyoid  and  thyroid  to  sufficient  extent;  the  carotid  sheath 
is  now  fully  exposed  and  should  be  drawn  outwards  with  the  sterno- 
mastoid  and  retained;  separate  the  thyroid  body  as  far  as  it  may  be 
necessary  with  the  handle  of  the  knife  and  draw  it  inwards;  now 
draw  the  larynx  somewhat  forwards,  turn  it  slightly  upon  its  long 
axis,  and  pass  the  finger  behind  it  to  discover  the  position  of  the 
foreign  body;  if  it  is  not  found,  pass  a  pair  of  long  curved  forceps 
well  down  into  the  pharynx,  through  the  month,  open  them  so  as  to 
press  the  walls  of  the  tube  well  towards  the  wound  as  a  guide,  care- 

1  a.  R.  ^racleod.         2  T.  Brvant.         3  P.  S.  Wales.       <  B.  W.  Richardson. 
6  A.  Willett.  c  G.  Pollock. 


THE  STOMACH. 


381 


fully  avoiding  the  recurrent  laryngeal  nerve;  open  the  tube  sufficiently 
to  admit  the  finger,  and  extend  the  cut  upwards  into  the  pharynx  or 
downwards  along  the  cesophagus,  as  may  be  necessary  to  reach  the 
object  sought;  search  for  the  foreign  body  with  the  finger,  and  when 
found,  extract  it  by  means  of  suitable  forceps ;  the  wound  should  not 
be  closed  with  sutures  ;  for  the  first  few  days  feed  the  patient  through 
a  tube  passed  by  the  mouth  below  the  wound. ^  The  incision  may  be 
made  in  the  median  line,  as  for  tracheotomy,  the  sterno-hyoid  mus- 
cles separated,  the  isthmus  of  the  thyroid  body  divided  between  two 
ligatures  tied  around  it,  the  left  lobe  turned  over  and  the  cesophagus 
sought  and  opened  behind  it.^ 

5.  Resection  of  the  oesophagus  is  effected  by  the  same  dissec- 
tion as  that  pursued  in  opening  the  tube. 


CHAPTER  XXXV. 


THE  STOMACH. 

Thr  stomach  occupies  the  left  hypochondriac  region,  extending 
through  the  epigastrium  into  a  small  part  of  the  right  hypochondriac 
region. 

Above  it  is  the  diaphrapm  and  liver;  below,  the  transverse  colon;  in  front,  tiie 
abdominal  wall;  beliiud,  the  pancreas;  to  the  right,  the  liver;  and  to  the  left, 
the  spleen.-^ 

1.  Medication  by  the  stomach  must  occasionally  be  effected  by 
instrumental  means,  as  in  the  removal  of  poi- 
sons and  the  injection  of  foods  and  remedies. 
For  these  purposes  the 
stomach  pump  (Figs.  350, 
351)  is  required. 

The  lever  g  (Fig.  351)  op- 
erates a  valve  causing  either 
induction  or  eduction  as  the 
instrument  may  be  required 
for  use  as  a  stomach  pump  or 
enema  syringe;  in  the  former 
case  the  flexible  tube,  A,  is 
screwed  to  the  lower  end,  and 
_  in  the  latter  to  the  side  branch 

\N>,^« .       of  the  instrument;  themouth- 

^^•^  ■  ^^  piece,  /,  is  held  between  the 

jaws  of  the  patient,  the  tube 
being  introduced  through  its 
central  opening.     A  stomach- 
pump  (Fig.  350)  may  consist  of  a  flexible  suction-pipe  attached  to  the  lower 
1  D,  W.  Cheever;  E.  Cock.  2  E.  Nelaton.  8  J.  Leidy. 


Fig.  350. 


382  OPERATIVE  SURGERY. 

opening,  h,  and  by  working  the  handle  the  contents  of  the  stomach  are  with- 
drawn and  ejected  through  the  brandi,  a;  a  quantity  of  warm  water  should  be 
first  pumped  into  the  stomach;  d  is  a  tube  for  making  injections;  y  is  a  gag 
or  mouth-piece,  placed  between  the  teeth,  through  which  the  flexible  pipe  is 
inserted ;   c,  d,  e,  are  for  enemas. 

The  pump  is  used  as  follows:  place  the  patient  in  a  chair,  with 
the  head  thrown  back  and  supported,  and  the  mouth  widely  opened; 
oil  the  tube  and  curve  the  end  slightly,  that  it  may  more  readily  fol- 
low the  curve  of  the  pharynx;  press  down  the  tongue  with  the  fin- 
ger and  pass  the  curved  end  rapidly  along  the  roof  of  the  mouth  into 
the  pharynx,  but  without  touching  the  soft  palate,  which  is  spas- 
modically drawn  upwards;  now  bend  the  head  slightly  forwards  to 
give  a  uniform  curve  to  the  cervical  and  dorsal  vertebrae,  and  push 
the  tube  gently  but  firmly  onward  to  the  stomach;  if  resistance  is 
encountered,  withdraw  it  slightly  and  again  press  it  forwards;  the 
only  danger  is  the  liability  of  the  tube  to  enter  the  larynx;  if  the 
patient  is  insensible,  or  resists  the  introduction,  the  gag  i  (Fig.  S.^l), 
y'(Fig.  350)  must  be  placed  between  the  teeth  and  the  tube  inserted 
through  the  hole;  if  the  gag  is  not  present,  a  tube  may  be  passed 
along  the  floor  of  the  nostril  into  the  pharynx.  If  the  tube  is  intro- 
duced to  remove  matters,  as  poisons,  first  inject  warm  water  each 
time  suction  is  made,  and  in  excess  of  the  amount  withdrawn. 

2.  Alimentation  by  fistula  of  the  stomach  is  indicated  when 
death  is  imminent  from  inanition  depending  upon  closure  of  the 
oesophagus,  as  from  cancer,  cicatrices  from  swallowing  caustic  mat- 
ters, syphilis ;  the  method  of  accomplishing  this  object  is  by  the 
formation  of  a  fistulous  passage  through  the  walls  of  the  stomach 
and  of  the  abdomen.  The  operation  has  until  recently  been  fol- 
lowed by  death  in  a  few  hours,  or  at  most,  a  few  days;  but  a  period 
of  fortv  days^  finally  supervened,  and  at  length  complete  success  was 
attained. 2  The  failure,  hitherto,  has  been  Lirgely  due  to  the  fatal 
nature  of  the  disease  of  the  oesophagus,  and  the  delay  in  the  opera- 
tion ;  it  is  therefore,  advisable,  to  operate  earlier.^  This  is  especially 
important  since  the  introduction  of  the  antiseptic  method,  for  the 
danger  of  intervening  peritonitis  is  comparatively  slight.  Chloroform 
should  be  given,  unless  the  patient  can  be  relied  on  to  remain  per- 
fectly still,  experience  having  proved  that  vomiting  is  not  general.* 
Gastrostomy,^  the  formation  of  a  fistula  of  the  stomach,  has  been 
successfully  performed  as  follows :  '^  — 

The  case  was  stricture  of  the  oesophagus,  caused  by  swallowing  acids,  in  a  boy 
eight  years  of  age.  The  skin  was  cut  through  for  a  length  of  about  two  inches, 
in  a  diagonal  direction,  running  from  right  to  left,  parallel  with  the  under  side 
of  the  cartilaginous  portion  of  the  eighth  left  rib,  and  at  a  distance  of  a  finger's 

1  S.  Jones.     2  I,.  Verneuil;  F.  Trendelenburg.     3  T.  Bryant;  T.  R.  Pooley. 
4  A.  E.  Durham.  5  C.  S^dillot.  6  f.  Trendelenburg. 


THE  STOMACH. 


383 


breadth  from  it  1  (Fig.  352);  the  wall  of  the  abdomen  was  divided  in  the  same  di- 
rection as  far  a?  the  peritoneum,  and  the  left  rectus  at  the  same  time  cut  partly 
through;  all  the  vessels  were  then  carefully  tied,  and  after  the  bleeding  had  en- 
tirely stopped,  the  peritoneum  was  divided  in  the  same  direction  ;  the  edge  of 
the  left  lobe  of  the  liver  was  then  exposed  to  view,  rising  and  falling  with  the 
respiration,  and  also  a  piece  of  intestine,  which  might  have  belonged  either  to 
the  colon  or  to  tiie  stomach;  the  peculiar  construction  of  the  arteria  and  vena 
gastro-epiploica  maiie  the  junction  of  the  diaphragm  at  the  stomach  so  character- 
istic that  all  doubt  disappeared  as  soon  as  these  vessels  were  exposed  to  view; 
the  stomach  had  slirunk  together  and  attached  itself  to  the  vertebral  column; 
its  front  side  was  now  grasped  at  a  point  corresponding  best  with  the  incision, 
drawn  somewhat  forward  out  of  the  opening,  and  tixcd  temporarily  in  the  open- 
ing by  two  acupuncture  needles  stucic  through  it  transversely:  the  two  needles 
rested  crosswise  on  the  outer  surface  of  the  abdomen  (Fig.  35.3);  in  order  that 


Fig.  -3.53. 

the  peritoneum  should  with  cetlainty  be  included  in  the  sewing  up,  the  edge  of 
it,  where  cut,  was  grasped  with  pincettes  and  drawn  forward  and  secured  by 
laying  the  pincettes  over  on  one  side;  for  the  stitching,  moderately  strong  silk 
was  used,  and  the  stitches  were  so  arranged  that  the  outer  skin,  the  wall  of  the 
abdomen,  and  the  peritoneum  were  pierced,  and  the  wall  of  the  stomach  taken 
upas  much  as  possible  in  its  entire  thickness:  fourteen  stitches  were  made;  after 
the  sewing,  which  surrounded  a  piece  of  the  stomach  wall  in  the  form  of  a  circle 
about  five  eighths  of  an  inch  in  diameter,  was  completed,  the  stomach  wall  was 
cut  through  within  this  circle  crosswise,  and  a  drain-pi{)e  inserted  in  the  stomach, 
which  was  found  to  be  perfectly  empty;  the  whole  operation  was  conducted 
under  antiseptic  precautions. i 

The  temporary  securing  of  the  front  part  of  the  stomach-wall  in  the  incis- 
ion by  means  of  acupuncture  needles  stuck  through  crosswise  and  resting  tlat 
on  the  outside  of  the  abdomen,  is  to  be  recommended,  also  the  bringing  forward 
the  cut  edge  of  the  peritoneum  by  means  of  pincettes;  the  difficulty  of  finding 
the  stomach  with  so  small  an  opening  in  the  abdomen  deserves  some  considera- 
tion, for  the  mistake  has  been  made  of  sewing  up  the  colon  instead  of  the  stom- 
ach. The  diaphragm  and  the  vena  gastro-epiploica,  which  is  seen  more  dis- 
tinctly than  the  artery,  will  always  be  the  safest  guides.  It  is  not  desirable  to 
1  W.  Tbomsca. 


384 


OPERATIVE  SURGERY. 


make  tlie  fistula  lars^er  than  is  absoliitelj'  necessary  for  the  purpose  of  fixing  a 
drain-pipe  of  about  five  sixteenlhs  of  an  inch;  there  is  not  much  gained  for  llie 
nourisliment  by  a  large  opening,  for  in  the  normal  method  of  feeding  through 
the  oesophagus  the  food  does  not  reach  the  stomach  in  uubrniien  bites,  but  in  a 
state  of  coarse  pulp,  and  the  attempt  to  surpass  nature  in  this  respect  cannot  be 
conducive  of  very  beneficial  results.  Apart  from  this,  a  large  opening  has  great 
disadvantages.  It  necessitates  having  a  special  apparatus  for  closing  the  en- 
trance, where,  as  with  a  small  fistula,  it  is  onlj'  necessary  to  put  in  a  suitable 
drain-pipe  and  cork  it  up  from  the  outside,  to  close  the  stomach  entirely.  This 
kind  of  stopping  is  perfectly  water-tight,!  because  the  somewhat  swollen  mucous 
membrane  of  the  stomach  sets  itself  close  against  the  drain-pipe.- 

The  after-treatment  requires  careful  management  of  the  wound 
and  diet;  the  stitches  were  removed  on  the  third  and  fourth  days; 
the  food  was  introduced  into  the  stomach  by  means  of  a  syringe,  and 
consisted  of  meat  parings,  soft  boiled  eggs,  and  milk.  The  final  ar- 
rangement for  taking  food  is  through  a  long  tube  fastened  to  a  drain 
pipe  in  the  fistula  (Fig.  354). 

In  feeding,  the  oesophagus  is  removed  to  the  outside,  otherwise  the  process  is 
as  much  as  possible  like  the  natural  one;  the  boy 
tastes  his  food  as  before ;  the  masticated  and  sali- 
vated matter  remains  partly  in  his  mouth  and  is 
partly  swallowed  down  into  the  cesophagus,  after 
which  he  places  the  tube  in  his  mouth,  and  sends 
the  food  by  a  slight  choking  and  spitting  motion, 
into  the  tube,  and  lets  it  glide  down  into  the  stom- 
ach, assisting  it  by  blowing  slightly  with  the  mouth; 
then  he  shuts  the  pinchcock,  which  he  had  previ- 
ously opened,  and  recommences  the  process  afresh. 
In  this  manner  he  is  made  independent;  he  runs 
and  jumps  almost  the  whole  day  with  the  drain- 
pipe in  the  fistula  without  a  trace  of  the  contents 
of  the  stomach  flowing  out;  the  neighborhood  of 
the  fistula  remains  dry. 

Or,  make  a  curvilinear  incision  with  the 
convexity  towards  the  median  line,  from  the 
sternal  extremity  of  the  seventh  intercostal 
downwards  and  outwards  for  nearly  four  inches.  Exposing  the  sheath 
of  the  rectus  muscle,  slit  it  up  and  separate  the  fibres  of  the  muscle 
with  the  fingers  and  scalpel,  the  cutting  edge  being  used  as  little  as 
possible,  to  avoid  hasmorrhage ;  divide  the  posterior  lamella  of  the 
sheath  of  the  rectus,  the  transversalis  fascia,  and  the  peritoneum,  suc- 
cessively, on  the  director;  the  stomach  will  now  appear  projecting  be- 
neath the  margin  of  the  liver;  seize  the  stomach  with  forceps  having 
fine  stroni-  teeth,  and  pass  a  curved  needle,  armed  with  strong  silver 
wire,  through  its  anterior  wall  in  the  direction  of  the  vertical  line 
of  the  body,  the  points  of  entry  and  exit  of  the  needle  being  about 

1  L.  Verneuil.  *  F.  Trendelenburg. 


Fig.  354. 


THE  STOMACH.  385 

an  inch  and  a  quiirtcr  apart;  now  pass  two  other  needles  armed  in 
the  j-anie  manner  from  left  to  right,  and  make  them  eross  the  first  at 
right  angles  (Fig.  35;));  the  wires  thus  inelude  the  part  to  be  ojjened, 
which  will  be  at  a  point  about  two  inches  to  the  left  of  the  pylorus; 
withdraw  the  first  wire,  and  with  scissors  open  the  stomach  in  a  per- 
pendicular direeiiou  to  the  extent  of  an  inch,  exposing  the  wires  (Fig. 
356);  divide  them  and  convert  the  wires  into  sutures  (Fig.  357);  after 
the  stomach  is  opened,  make  constant  traction  upon  it  to  jirevent 


1 


a 


Fig.  355.  Fig.  356.  Fig.  357. 

the  escape  of  its  contents  into  the  abdominal  cavity;  now  attach  by 
numerous  silver  sutures  the  edges  of  tlie  viscus  to  the  opening  in  the 
abdominal  walls  so  as  to  secure  the  most  accurate  approximation; 
introduce  a  tube  with  a  single  flange,  resting  upon  the  edges  of  the 
external  wound,  and  confined  by  means  of  tapes  passed  around  the 
body ;  close  the  remaining  wound  in  the  abdominal  parieties  by  or- 
dinary sutures.* 

Other  methods:  the  incision  may  be  crucial ^^^  or'it  may  be  over  the  left  semi- 
lunaris, and  the  stomach  entered  near  the  greater  curvature  ;3  or  make  the  in- 
cision al)out  two  inches  in  length  along  the  outer  edge  of  the  rectus  muscle  in 
the  left  hypochondriac  region,  commencing  at  the  cartilages  and  opposite  the 
space  between  the  seventh  and  eighth  ribs;*  or  begin  the  incision  at  the  inner 
border  of  the  ninth  rib,  and  carry  it  vertically  downward ;  "  or,  make  the  incision 
from  the  extremity  of  the  seventh  rib,  vertically  downward,  about  three  inches 
along  the  margin  of  the  rectus  muscle.  The  coats  of  the  stomach  are  seized  with 
forceps,  drawn  into  the  wound,  and  opened  about  three  fourths  of  an  inch  with 
scissors.**  The  quill  suture  has  been  used  to  unite  the  wound  of  the  stomach  to 
that  of  the  skin;  to  do  this,  first  pass  the  needles  that  have  already  traversed 
the  stomach,  and  are  still  armed,  through  one  side  of  the  wound,  and  with  a 
second  needle  draw  the  free  ends  of  the  ligature,  when  threaded,  through  the 
otlier;  there  will  then  be  two  double  ligatures  through  each  side  of  the  opening 
in  the  stomach  and  the  margin  of  the  wound;  tie  the  two  ends  over  two  pieces 
of  bougie,  one  introduced  against  the  inner  surface  of  the  stomach,  and  the  other 
upon  the  integument,  the  bougies  admirably  compressing  the  thin  walls  of  the 
integuments  and  retaining  them  there."     In  general,  after  the  operation,  food 

1  F.  F.  Maurv.    2  c.  Sedillot.    »  a.  E.  Durham.    ••  C.  Foster.    6  S.  Jones. 
6  T.  B.  Curling.  7  f.  Bryant. 

25 


386  OPERATIVE  SURGERY. 

should  not  be  given  by  the  stomach  for  a  few  hours,  nourishment  being  main- 
tained by  the  rectum. 

4.  Wound  of  the  stomach  is  recognized  by  its  position,  its 
depth,  and  its  special  direction,  the  escape  of  food  or  drink,  vom- 
iting of  blood,  pain  and  faintness,  witli  pallor,  cold  extremities, 
small  and  frequent  pulse,  thirst,  sinjjultus,  and  tympanitis  ;  if  the 
organ  is  empty  there  will  be  no  extravasation,  and  the  amount  of 
hsemorrliage  will  depend  upon  the  extent  to  which  the  curvatures 
and  extremities,  where  the  arteries  are  located,  ai'e  involved.  Ocu- 
lar inspection,  when  possible,  and  the  introduction  of  the  educated 
finger  into  the  wound,  give  the  only  positive  evidence  of  these  lesions 
of  the  stomach.^  These  wounds  must  be  carefully  closed  by  suture.^ 
Gastroraphy,  or  suture  of  the  stomach,  should  be  so  performed  as 
to  secure  the  inversion  and  approximation  of  the  serous  surfaces.^ 
If  the  wound  is  a  mere  puncture,  pinch  up  the  lips  of  the  opening 
and  include  it  in  a  ligature;  in  small  wounds,  whatever  their  direc- 
tion, make  the  interrupted  suture  with  a  fine  cambric  needle,  and 
armed  with  a  small  but  strong  and  well-waxed  thread;  pass  the 
needle  from  one  side  of  the  wound  to  the  other,  across  all  the 
tunics  of  the  bowel  except  the  mucous,  in  such  a  manner  as  to 
bring  the  serous  edges  in  the  most  accurate  apposition;  place  the 
sutures  about  two  lines  apart,  and  introduce  the  entire  number  be- 
fore any  are  tied  (Fig.  360)  ;  secure  the  ends  with  double  knots,  and 
cut  off  close,  so  that  as  the  sutures  become  detached  they  will  fall 
into  the  cavity  of  the  stomach;  when  the  wound  is  of  unusual  length 
select  the  continued  suture  (Fig.  358);  each  stitch  including  not  more 
than  half  a  line  of  substance;  the  ends  of  the  thread  being 
well  secured  at  each  angle  of  the  opening  should  be  cut 
close  to  the  surface  of  the  tube.^  Accessible  shot  wounds 
of  the  anterior  wall  should  be  treated  by  suture,  but  the 
bruised  edges  should  not  be  refreshed,  for  as  the  loss  of 
substance  is  confined  to  the  muscular,  connective,  and 
mucous  tissue,  the  serous  membrane  remains  sufficiently 
organized  to  hold  stitches ;  what  sloughing  there  may  be 
from  the  inner  tunics  will  fall  into  the  cavity  of  the  stom- 
ach ;  cut  the  ends  of  the  sutures  short,  and  return  the 
Fig.  358.    ^yi^ojg  within  the  cavity  of  the  abdomen.^ 

Take  a  short  stitch  on  one  side  of  the  wound,  about  two  lines  and  a  half  from 
the  edge,  including  only  the  peritoneal  and  muscular  coats,  then  carry  the  needle 
across  the  gap  and  take  a  similar  stitch  on  the  opposite  side;  repeat  the  stitches, 
the  interval  not  exceeding  the  sixth  of  an  inch;  when  the}'  are  all  arranged, 
draw  them  firmly  together,  tie  with  a  double  knot  and  cut  off  the  ends;  the 
wound  is  thus  completely  closed  in  every  portion  of  its  extent;  its  lips  being 
inverted,  approximate   their  serous   surfaces ^   (Figs.   359,    360).      Or,  arm  a 

1  G.  A.  Otis.  2  s.  D.  Gross.  3  M.  Lembert;  S.  D.  Gross. 


THE  STOMACH. 


387 


waxed  thread  nt  either  end  with  a  small  glover's  needle  ;  introduce  one  parallel 
to  the  wound  without  and  back  of  one  of  its 
angles  about  one  line,  and  bring  it  out  on  the 
peritoneal  surface  after  traversing  the  bowel 
for  about  the  sixth  of  an  inch;  practice  tlie 
same  upoti  tlie  opposite  side  with  the  second 
needle;  cross  the  threads,  and  pass  the  right 
needle  through  the  puncture  made  by  the 
left,  and  conversely;  repeat  the  stitch  as  often 
as  may  be  necessary  to  completely  close  the 
wound ;  tighten  the  threads  by  faking  each 
successively  at  the  transverse  points  with  dis- 
secting forceps,  and  make  suitable  traction,  at 
the  same  thue  de|)ressing  the  lips  of  the  wound ; 
tie  the  threads,  and  cut  them  close;  the  approximation  is  so  complete  that  no 
trace  of  the  threads  or  knot  appear  externally.l  (Figs.  361,  302,  3G3,  and  3G5). 


Fig.  359. 


Fig.  360. 


Fig.  301. 


Fig.  362. 


Fig.  303. 


Fig.  36-1. 


Tlie  after-treatment  consists  in  administering,  for  a  few  days,  ice 
in  quantities  to  allay  thirst  and  quiet  irritability ;  after  that  a  little 
arrowroot,  tapioca,  sago;  if  gastroraphy  has  been  neglected,  or  is 
impracticable,  withhold  everything  by  the  mouth  until  the  edges  of 
the  wound  have  contracted  adhesion  to  the  ailjacent  parts,  and  rely 
upon  the  ap[)lication  of  ice  to  the  epigastrium,  nourishing  enemata, 
and  morphia  to  relieve  pain.' 

6.  Foreign  bodies  are  often  introduced  into  the  stomach  accident- 
ally or  intentionally,  and  unless  removed  may  create  fatal  inflamma- 
tion and  ulceration ;  they  may  remain  in  the  stomach  for  a  certain  pe- 
riod without  much  inconvenience,  but  sooner  or  later  they  produce  se- 
rious consequences;  if  the  substance  be  a  piece  of  money,  or  anv  other 
small  body,  it  will  be  passed  off,  often  without  much  discomfort,  in 
the  course  of  a  few  days,  sometimes  within  fortj'-eight  hours  of  hav- 
ing been  swallowed;  but  should  the  substance  be  a  bone  or  other  ir- 
regular-shaped or  uneven  mass,  it  may  be  some  weeks  before  it  es- 
capes through  the  rectum.  The  early  symptoms  of  a  forei<Tn  body 
in  the  stomach  will  depend  very  much  on  the  shape  and  nature  of 
1  M.  Gely ;  G.  A.  Otis.  2  g.  D.  Gross. 


388  OPERATIVE  SURGERY. 

the  mass;  a  pin,  or  sharp  bone,  or  pointed  instrument,  will  cause 
jiain  in  the  epigastrium,  often  of  a  severe  character,  a  sense  of 
•weight  and  discomfort  at  the  stomacli,  a  desire  to  vomit,  or  an  ejec- 
tion of  the  contents  of  the  stomach  witli  blood;  if  the  person  is  thin 
and  the  substance  large,  it  may  occasionally  be  detected,  through  the 
abdominal  walls.  A  sharp-pointed  mass  may  gradually  penetrate 
the  walls  of  the  stomach  and  ultimately  escape  externally;  needles 
and  pins  may  escape  through  various  structures  and  make  their  exit 
at  some  distance  from  the  point  at  which  they  escaped  from  the 
stomach.  The  treatment  must  depend  upon  the  natui'e  and  shape 
of  the  substance;  pieces  of  money  and  many  other  bodies  are  aided 
in  their  passage  by  bulky  ingesta,  and  hence  it  is  better  to  avoid 
purgatives,  and  rather  allow  food  plentifully  in  order  to  have  tne 
foreign  body  embedded  in  and  surrounded  by  feculent  matter.  If 
the  body  is  retained  in  the  stomach  and  life  becomes  endangered  by 
lis  presence,  the  stomach  should  be  opened  and  the  foreign  body  re- 
moved. Gastrotomy,  section  of  the  stomach,  for  the  removal  of  for- 
eign bodies,  has  proved  an  entirely  feasible  and  successful  operation; 
the  method  of  procedure  is  in  detail  the  same  as  gastrostomy,  but 
the  wound  must  be  closed  by  sutures. 


CHAPTER  XXXVI. 

THE  DUODENUM;   THE  JEJUNUM;   THE   ILEUM. 
I.    THE  DUODENUM. 

This  is  the  shortest  and  widest  part  of  the  small  intestine,  vary- 
ing in  diameter  between  an  inch  and  a  half  and  two  inches,  and  is 
ten  to  twelve  inches  in  length. 

It  has  no  mesentery,  and  is  only  partially  covered  by  the  peritoneum:  in  its 
course  it  describes  a  single  large  curve,  the  convexitj'  towards  the  right  and  the 
concavity  embracing  the  head  of  the  pancreas,  and  passing  from  the  pylorus  to 
the  under  surface  of  tlie  liver,  thence  downward  in  front  of  the  right  kidney  as 
low  as  the  second  or  third  lumbar  vertebra,  where  the  bowel  turns  across  to  the 
left,  and  ascends  obliquely  for  an  inch  or  more.'^ 

1.  Foreign  bodies  may  enter  the  duodenum  from  the  stomach, 
or  from  the  liver  and  gall  bladder.  Of  the  former,  are  masses  of 
pins,  collections  of  hair  and  threads,  and  of  husks  of  grains,  as  well 
as  large  bodies,  like  spoon-handles,  knives.  Of  the  latter,  are  biliary 
calculi,  which,  if  small,  pass  readily  through  the  bowel,  but,  if  large, 
may  enter  it  by  ulceration,  and  form  a  permanent  obstruction.  The 
symptoms  are  those  of  gastric  and  hepatic  derangement,  until  the  ob- 
1  Quain's  Anatomy. 


THE  JEJUXi\\[  AXD  ILEUM.  389 

Ptniction  becomes  considfrabk-;  then  the  tumor  may  be  perceptible; 
the  vomiting  is  pe^^istent,  but  never  stercoraceous.  No  operative 
interference  lias  been  undertaken. 

2.  Woiuids  of  the  duodenum,  generally  fatal,  involve  other  im- 
portant t^tructures;  as  the  descending  and  middle  portions  have  no 
jiniper  peritoneal  coat,  but  are  loosely  fixed  between  the  laminie  of 
the  meso-eolon,  this  part  may  be  wounded  without  extravasation  of 
its  contents  into  the  great  peritoneal  cavity.^  The  treatment  must 
be  on  ge..eral  principles,  as  no  operation  has  been  devised. 

II.     THE  JKJUXUM  AND  ILEUM. 

The  jejunum  commences  on  the  left  side  of  the  second  lumbar 
vertebra;  it  is  attached  and  supported  by  the  mesentery  and  its  con- 
volutions are  in  the  umbilical  and  left  iliac  regions ;  the  ileum  is 
continuous  with  the  jejunum,  and  its  convolutions  occupy  part  of 
the  umbilical,  right  iliac,  hypogastric,  and  pelvic  regions,  and  from 
the  latter  it  ascends  to  the  right  iliac  fossa,  where  it  ends  in  the 
c:pcuin.'^ 

1.  "Wotmds  of  the  jejunum  and  ileum  from  penetrating  instru- 
ments are  frequent,  owinir  to  the  great  length  of  these  bowels,  their 
floating  condition,  and  the  large  space  over  which  they  are  spread. 
In  general,  the  wounds  are  oblique,  but  occasionally  they  are  trans- 
verse, and  sometimes,  though  rarely,  longitudinal;  they  vary  also 
from  the  smallest  puncture  to  lesions  inches  in  length,  or  even  to 
complete  division  of  the  tube.^  The  danger  is  in  proportion  to  the 
liability  to  extravasation  of  the  contents  of  the  bowel,  and  this  de- 
pends upon  the  extent  and  nature  of  the  wound.  If  the  wound, 
whatever  its  direction,  does  not  exceed  four  lines  in  length,  or  a 
third  of  an  inch,  nature,  aided  by  appropriate  therapeutic  meas- 
ures, will,  in  many,  if  not  in  a  majority  of  cases,  be  fully  com- 
petent to  effect  a  cure ;  but  when  the  opening  is  six  lines  in  ex- 
tent, whether  transverse,  oblique,  or  longitudinal,  there  is  almost 
invariably  an  escape  of  faecal  matter,  followed  by  fatal  peritonitis.' 
In  punctured  wounds  the  opening  is  contracted  by  the  circular  and 
longitudinal  filires  and  closed  by  the  eversion  of  the  mucous  lining; 
in  transverse  wounds,  there  is  slight  gaping  from  the  contraction  of 
the  longitudinal  fibres,  but  the  calibre  is  diminished  by  the  con- 
traction of  the  circular  muscular  layer,  and  the  pouting  of  the  mu- 
cous membrane  impedes  the  escape  of  faecal  matters;  in  complete 
transverse  section  of  the  gut,  the  divided  extremities  are  so  separated 
and  puckered  as  to  render  it  dillicult  to  distinguish  the  upper  from 
the  lower  portion,  except  by  the  escape  of  faeces;  in  large  longitudi- 
nal wounds,  the  contraction  of  the  circular  muscular  fibres  causes 

1  G.  A.  Otis.  2  Quaiu's  Aiiat.  8  S.  D.  Gross. 


390  OPERATIVE  SURGERY. 

wide  gaping  of  the  edges,  and  permits  the  escape  of  the  contents  of 
the  bowel.^  Tlie  most  important  immediate  symptoms  of  lesion  of 
the  bowels  are,  shook,  pallor,  nausea,  small  and  tremulous  pulse, 
sudden  tympanitis;  secondary  symptoms  are,  discharge  of  blood  from 
the  anus,  pain  in  the  abdomen,  dull  and  aching  or  sharp  and  colicky, 
tenderness,  posture  so  as  to  relieve  pressure. '■^  But  the  diagnosis  is 
positive  only  Avhen  the  bowel  protrudes  from  the  external  wound  and 
can  be  inspected,  or  when  there  is  an  escape  of  the  contents  of  the 
bowel  externally.  If  the  bowel  cannot  be  examined,  it  is  well  to  as- 
certain, first,  the  position  of  the  parietes  at  the  time  of  the  accident, 
the  size  and  shape  of  the  instrument;  then,  if  the  opening  in  the 
wall  of  the  abdomen  is  large,  place  the  part  and  body  as  nearly  as 
possible  in  the  ])Osition  they  were  when  the  injury  was  inflicted,  and, 
avoiding  all  officious  interference,  carefully  explore  with  the  index 
finger,  aseptic,  or  a  director,  to  determine  whether  the  wound  involve 
the  muscles  only  or  the  muscles  and  peritoneal  cavity.^  The  treat- 
ment of  all  punctured  and  incised  wounds  of  the  intestines,  attended 
with  protrusion,  consists  in  closing  the  intestinal  wound  by  suture, 
and  reducing  the  protruded  viscus,  unless  its  structure  is  irretrieva- 
bly disorganized,  and  the  adoption  of  the  alternative  of  establishing 
an  artificial  anus  is  compulsory  ;  ^  even  if  the  wound  is  not  more 
than  a  line  and  a  half  in  length,  the  bowel  ought  not  to  be  returned 
witliout  the  suture,  lest  faecal  extravasation  occur.^  As  the  suture  is 
intended  to  prevent  extravasation,  there  must  be  the  most  perfect 
adaptation  of  the  edges  of  the  wounded  intestine;  when  finished,  the 
threads  must  be  cut  close  to  the  knot,  and  the  bowel  returned  to 
its  natural  bed,  without  any  measures  being  taken  to  retain  the 
wountled  portion  near  the  external  wound;  on  the  replacement  of 
the  bowel  the  latter  must  be  treated  as  if  no  other  injury  had  oc- 
curred.3  In  wounds  of  the  intestines,  unattended  by  protrusion,  if 
there  is  danger  of  extravasation,  the  external  wound  should  be 
enlarged,  and  the  wound  in  the  intestine  closed  by  a  proper  suture.* 
Enteroraphy,  suture  of  the  bowel,  in  itself  one  of  the  most  inno- 
cent of  operations,  is  best  accomplished  by  the  conniion  interrupted 
suture,  which,  judiciously  employed,  gives  excellent  results,  what- 
ever may  be  the  situation,  direction,  or  extent  of  the  wound.*  The 
opei'ations  described  for  wounds  of  the  stomach  may  be  performed  in 
wounds  of  the  intestine.  An  indispensable  element  in  the  treatment 
of  these  wounds  is  the  constant  and  intelligent  use  of  antiseptics. 

If  the  wound  involve  the  entire  circumference,  proceed  as  follows:  determine 
which  is  the  upper  end  of  the  gut;  dissect  away  the  mesentery  a  tliird  of  an  inch 
from  each  end  and  arrest  the  bleeding  that  ensues;  then,  liolding  the  upper  ex- 
tremity by  the  left  hand,  with  the  right  insert  a  stitch  through  it  two  thirds  of 

1  G.  A.  Otis.        2  s.  D.  Gross.        a  g.  Pollock.        *  G.  A.  Otis;  S.  D.  Gross. 


THE  JEJUNUM  AND  ILEUM. 


391 


Fig.  365. 


an  inch  from  the  divided  margin  (Fit,'-  305)  and  give  the  loop  into  the  liands  of 
an  assistant;  introduce  a  second  stitcii  in  like  manner  at  the 
opposite  or  mesenteric  side  of  the  bowel;  then  with  the  lin- 
gers, or  with  (hit  forceps,  invert  the  lips  of  the  lower  portion, 
which  is  a  diliicult  jjrocedurc;  when  accomplished,  maintain 
the  inverted  heiTi  hetween  the  left  index  linger  introduced, 
and  the  thumb,  and  along  the  finger,  as  a  guide,  introduce 
the  inner  end  of  the  first  loop  inserted  in  the  upper  portion 
of  the  bowel,  and  in  like  manner  the  second;  by  gentle  trac- 
tion upon  the  two  loops,  invaginafe  the  upper  portion  within 
the  lower  (Fig.  3(10);  the  loops  may  now  be  tightened  and 
knotted  or  twisted,  or  the  hem  may  be  traversed  by  the  outer 
ends  of  the  two  loops  (Fig.  307)  and  the  stitch  then  tight- 
ened and  secured  by  torsion  or  by  knot;  bring  the  ends  of  the  ligature  out  at 

the  lower  angle  of  the  external  wound; 

withdraw   the   threads  on   the  fourth  or 

fifth  day  by  gentle  traction. i 

2.  Gunshot  -wounds  of  the  small 
intt'stiiies  are  severe  in  proportion 
to  the  size  of  the  ball;  larrre  projec- 
tiles <jeiierally  cause  hopeless  evis- 
cerations  ;  niusket-balls  commonly 
partially  or  completely  divide  the 
Fio.  300.  calibre  of   the  small   bowel;    pistol        Fig.  367. 

or  carbine  balls  often  make  single  or  twin  perforations. 

Shot  injuries  of  the  duodenum  are  commonly  accompanied  with  mortal  lesions 
of  adjacent  parts ;  the  jejunum  is  very  liable  to  [)erforation  by  shot,  and  these 
wounds  are  often  complicated  by  lesions  of  the  adjacent  viscera  or  of  the  mesen- 
teric arteries,  but  there  is  not  immediate  extravasation  owing  to  the  emptiness 
of  the  bowel:  the  ileum,  though  somewhat  protected  posteriorly  and  laterally, 
is  fully  exposed  in  the  umbilical,  hypogastric,  and  right  iliac  regions. ^ 

The  treatment  of  shot  injuries  of  the  small  bowel  which  protrudes 
is  by  enteroraphy,  as  in  incised  wounds.  If  the  bowel  do  not  pro- 
trude, the  rule  of  practice  is  still  non-interference."  If  the  woundcl 
intestine  becomes  attached  to  the  external  wound  an  artificial  anus 
is  formed  and  the  contents  of  the  bowel  are  discharged  external  at 
this  opening.  It  becomes  a  matter  now  of  great  importance  to  re- 
store the  passage  by  the  removal  of  the  septum,  or  the  two  apposed 
walls  of  the  intestine. 

There  is  a  growing  conviction  that  the  time  has  come  when  gun-shot  and 
other  wounds  of  the  abdomen,  and  perforations  of  the  intestines  should  be 
treated  by  opening  the  peritoneal  cavity  and  washing  out  or  draining  off  the 
septic  fluids  that  would  otherwise  poison  the  blood,''  and  this  practice  is  ren- 
dered the  more  safe  and  feasible  by  the  use  of  disinfecting  spray  during  the 
whole  operation. 


1  Jobert  de  I.amballe;  O.  A.  Otis. 
S.  D.  Gross;  Xeudorfer;  F.  11.  Hamilton. 


2  G.  A.  Otis. 
*  J.  M.  Sims;  G.  A.  Otis. 


392 


OPERATIVE  SURGERY. 


Fig.  3G8. 


If  the  septum  is  slight,  dilate  both  ends  of  the  intestine  by  means 
of  lint  tents,  regularly  increased  in  size  and  retained  by  compress,  and 
follow  by  introducing  conical  plugs  into  the  external  opening,  thus 
forcing  the  septum  back  towards  the  abdomen,  and  leaving  the  two 
ends  of  the  intestine  opposite  each  other;  continue  treatment  until 
fasces  pass  freely  from  the  upper  to  the  lower  bowel;  subsequent  com- 
pression with  a  pad  and  truss  is  in  many  cases  followed  by  complete 
cicatrization.^  If  the  septum  is  prominent  and  unyielding,  it  must 
be  destroyed  by  the  enterotome,  selected  and  applied  thus:  Select  an 
instrument  with  serrated  edges  worked  by  a  screw  (Fig.  368) ;  place 

the  patient  on  the  back  and 
distinguish  the  upper  and 
lower  ends  of  the  bowel;  now 
take  one  branch  of  the  enter- 
otome in  the  right  hand  and 
pass  it  carefully  along  the  track  of  the  bowel  one  to  three  inches, 
according  to  the  depth  of  the  septum;  while  an  assistant  retains  this 
branch,  introduce  the  other  with  the  same  care  along  the  other  bowel; 
now  join  the  blades  and  tighten  them  sufficiently  to  compress  the 
opposed  serous  surfaces  firmly  together,  and  finally  to  desti'oy  the 
septum  by  strangulation  (Fig.  3GD);  after  a  few  days  the  instrument 
becomes  loose  and  finally  falls;  the  after  treat- 
ment requires  compress  and  truss  until  the 
wound  heals. '^ 


Other  metliods,  are  the  ligature  3  passed  through  the 
septum  and  frequently  tightened  until  firm  adhesions 
have  taken  ])lace  between  the  opposed  serous  surfaces, 
and  then  division  of  the  remainder  by  the  bistoury; 
destruction  of  the  septum  by  caustic,*  and  by  excision  ;5 
.        /I    /\  'y'^z'    suture  of  the  margins  of  the  wound  in  the  abdominal 

\  /J  /    ^<%xv3^^    wall ;  6  anaplasty. - 

4\w)        3.  Intussusception   of  the  jejunum  and 
'^'    ileum  is  most  frequent  in  adults,  at  the  aver- 
FiG.  .369.  age  age  of  thirty-four;^  but  it  may  occur  in  the 

infant.^  Owing  to  the  comparative  narrowness  of  the  tube  into 
which  the  invaginated  portion  of  the  bowel  descends,  strangulation 
and  congestion  are  speedy  and  intense,  and  sloughing  and  separation 
of  the  stranguUited  part  are  consequently  most  frequent.^"  It  follows 
that  this  invagination  generally  runs  an  acute  course;  impermeability 
is  immediate  and  permanent,  and  death  may  follow  in  from  three  to 
six  days,  with  or  without  peritonitis  or  perforation  ;  in  other  cases 
the  invaginated  portion  sloughs,  either  in  strips  and  shreds,  or  in  tu- 
bular sections,  between  the  eleventh  and  twenty-first  day.^^  The  gen- 
1  Desault.  2  Dupuytren.  3  p.  S.  Physick.  *  Vidal.  5  RayL^.  6  LeCat. 
7  Collier.    8  W.  Brintou.    9  J.  L.  Smith,    io  J.  S.  Bristowe.    "  0.  Leichtenstern. 


THE  JEJUNUM  AND  ILEUM.  393 

eral  syniiitoms  of  intussuFception  combine  a  variable  degree  of  ob- 
struction and  inflammation;  the  patient  is  seized  with  a  sudden, 
violent  pain,  often  exactly  localized  in  the  region  corresjKjnding  to 
the  intussusception,  and,  even  when  most  agonizing,  sometimes  dis- 
tinctly recognized  as  a  straining  or  tearing  sensation,  rarely  accom- 
panied by  rigors;  vomiting  follows,  which  may  subside  if  the  inflam- 
mation is  early  and  intense,  but  more  frequently  continues  and  be- 
comes stercoraceous  in  the  course  of  three  or  four  days.  The  tumor 
caused  by  the  intussusception  is  a  physical  sign  of  the  irreatest  value; 
though  of  small  size  in  many  cases,  especially  in  the  eailier  stages, 
and  often  obscured  by  the  distention  of  the  intestine,  yet  a  careful 
examination  will  usually  detect  its  presence. 

Tlie  chief  distinction  of  intussusception  from  all  other  varieties  of  obstruction 
IS  the  suddenness  of  the  invasion,  the  acuteness  of  the  i)ain,  tlie  rapi<lity  of  the 
prostratinj?  effect,  and,  above  all,  the  detection  of  the  intussusception  itsilf.i 

The  most  characteristic  features  of  intussusception  of  the  small  in- 
tines  are  the  violence  of  the  symptoms,  the  rapid  progress  of  the 
disease,  more  copious  ha;mon'hage  from  the  bowels,  blood  sometimes 
in  the  vomited  matters,  more  coinplete  obstruction,  the  discharges 
containinir  little  or  no  fa?cal  matters,  the  absence  of  tenesmus,  the 
tumor  small  and  situated  within  the  abdomen  and  often  in  the  hypo- 
gastrium.  The  indications  of  treatment  are:  (1)  the  use  of  enemata 
to  move  the  bowels,  emetics  and  purgatives  being  avoideil;  (2)  the 
administration  of  opium  to  alleviate  pain,  quiet  the  intestines,  pre- 
vent the  increase  of  invagination,  and  favor  both  the  reduction  of 
the  swelling  and  the  restoration  of  the  passage;  with  children,  it  must 
be  given  in  small  ([uantities  and  with  great  care,  but  for  adults  it  must 
be  used  watchfully  in  powerful  doses;-  hypodermic  injections  of  mor- 
phia are  generally  to  be  preferred.  The  tjiiestion  of  reducing  the  in- 
vagination demands  early  consideration,  and  must  be  determined  with 
due  regard  to  the  fatality  of  the  disease,  the  possibility  of  recovering 
in  each  individual  case,  with  or  without  sloughing  of  the  invaginated 
portion,  and  the  fact  that  rough,  forcible,  ill-timed  jiroceedings  will 
do  more  harm  than  good.'  The  value  of  the  various  methods  may 
be  estimated  as  follows:  (1)  Crude  mercury,  like  drastic  purgatives, 
should  never  be  administered  with  a  view  to  force  a  passage.  (2) 
Injections  of  air  and  fluids  are  of  doubtful  value,  for  they  rarely, 
if  ever  pass  the  ileo-ca>cal  valve  from  the  colon  to  the  ileum  un- 
less the  iieo-caecal  sphincter  is  relaxed  by  opium  or  aniesthetics.^ 
(3)  Puncture  of  the  intestine  with  an  asjiirating  needle  may  be  made 
to  witlidraw  accumulated  gases;  if  carefully  performed  with  a  tine, 
disinfected  needle,  the  operation  is  quite  without  danger,  and  gives 
immediate  though  temporary  relief ;  ^  for  the  operation,  select  the 
1  \V.  Grintun.  2  Q.  Leichtensteru. 


394  OPERATIVE  SURGERY. 

smallest  aspirating  needle  and  employ  the  aspirator,  in  order  to 
create  powerful  suction  ;  if  the  pump  is  not  accessible,  the  common 
bulb  syringe^  may  be  attached  and  will  generally  prove  efficient;  dip 
the  needle  in  boiling  water  or  a  disinfectant  solution;  insert  the  needle, 
by  a  slight  rotary  motion,  into  the  most  pronunent  and  resonant 
point  of  the  abdomen  and  pump  out  all  of  the  gas;  withdraw  the 
needle  instantly  while  working  the  pump  in  order  that  no  matters 
contained  lodge  in  the  cellular  tissue;  a  small  trocar  and  canula  may 
be  used,  but  they  are  not  as  efficient  as  the  needle  and  aspirator.^ 
Laparatomy,  abdominal  section,  is  performed  for  the  purpose  of  ex- 
posing the  intussusception  and  reducing  it  by  manipulation  ;  the  op- 
eration has  received  but  limited  sanction  from  surgical  authorities, 
but  is  evidently  growing  in  favor,  especially  when  combined  with  dis- 
infection of  the  air  by  means  of  carbolized  spray.  It  may  be  under- 
taken at  the  earliest  ago,  having  proved  successful  in  the  infant 
of  six  months;  but  it  is  impoitant  that  it  should  be  performed  as 
early  as  practicable,  for  success  depends  largely  upon  the  condi- 
tion of  the  bowel;  and  when  the  strangulation  is  tight,  the  parts 
speedily  become  so  altered  by  swelling,  adhesion,  and  softening,  that 
no  amount  of  force  short  of  that  liable  to  cause  rupture,  will  suf- 
fice to  liberate  them.^  Operate  as  follows:  The  patient  being  fully 
under  the  influence  of  an  anesthetic,  and  the  atomizer,  if  used,  in 
operation,  make  an  incision  two  or  three  inches  in  length  in  the  me- 
dian line,  commencing  just  below  the  umbilicus,  a  6  (Fig.  352)  ;  on 
exposing  the  peritoneum,  open  it  cautiously  at  the  upper  angle  and 
introduce  two  fingers  previously  treated  with  carbolic  solution;  enlarge 
the  opening  to  the  required  extent;  with  the  same  fingers  explore  the 
bowels,  and  when  the  intussusception  is  discovered,  withdraw  it  suf- 
ficiently to  render  manipuUtion  easy;  effect  disinvagination  by  gentle 
traction  upon  the  two  portions,  or  by  pulling  the  enshoathing  layer 
downward  and  squeezing  the  lower  end  of  the  iiitussuscepted  gut.^ 
When  the  i-eduction  is  effected,  gently  rci)lace  the  escaped  bowels, 
an  act  often  requiring  great  patience  and  tact,  and  close  the  wound 
with  silver  sutures,  including  the  peritoneum;  support  the  walls  of 
the  abdomen  by  adhesive  plasters  and  bandages. 

5.  Strangulation  of  the  small  intestines  may  be  caused  by 
peritoneal  false  ligaments,  by  the  omentum  and  mesentery,  by  slits 
and  holes  in  different  organs,  by  diverticula,  by  the  appendix  vermi- 
formis,  by  internal  hernia,  and  by  twisting,  knotting,  and  compres- 
sion.* In  occlusion  of  the  jejunum,  collapse,  vomiting,  and  anuria 
usuall}'  appear  eai-ly  and  soon  reach  a  considerable  height;  the  course 
is  usually  rapid,  the  meteorism  inconsiderable,  limited  to  the  epigas- 

1  Davidson.  2  j.  Q.  Blake;  H.  J.  Bigelow.  3  H.  B.  Sands. 

4  0.  Leichtensteni. 


Tin-:  JEJUNUM  AND  ILEUM.  395 

trium,  or  entirely  wanting,  ;in<l  tlie  abdominal  wall  even  retracted; 
the  vomited  matter  is  stained  witli  bile,  greatly  discolored,  but  never 
feculent;  when  the  occlusion  is  of  the  lower  part  of  the  ileum,  the  me- 
teorism  is  noteworthy,  sometimes  limited  mainly  to  tlie  meso-  and  hy- 
pogastrium,  with  comparative  hoUowness  of  the  regions  corresponding 
to  the  colon;  the  course  is  also  rapid,  collapse,  vomiting,  and  sup- 
pression of  urine  appearing  early,  but  the  vomited  matters  soon  be- 
come feculent. >  In  the  treatment,  (1)  relieve  the  pain  by  full  doses  of 
opium;  (2)  attempt  to  reduce  the  strangulation  by  kneading  the  ab- 
domen while  the  patient  is  in  a  bath,  with  the  legs  drawn  up,  ot 
under  an  anajsthetic  ;  (3)  perform  laparotomy,  find  the  cause  of  the 
strangulation,  and  divide  bands  or  strictures;  (4)  if  the  bowel  is 
gangrenous,  or  obstructed  beyond  relief,  add  enterotomy  and  estab- 
lish an  artiticial  anus. 

6.  Obstruction  of  the  jejunum  and  ileum  may  occur  from  in- 
testinal and  gall  stones  and  foreign  bodies  swallowed  ;  they  lodge  most 
frequently  in  the  lowest  part  of  the  ileum,  one  or  two  inches  above 
the  ileocajcal  valve,  owing  to  the  diminution  of  the  calibre  of  the  in- 
testine as  it  approaches  the  ca2cum,  and  its  fixation  by  a  short  mesen- 
tery.^  Intestinal  stones,  enteroliths,  rarely  occlude  the  bowel  sud- 
denly, but  give  rise  to  premonitory  symptoms,  as  emaciations,  hypo- 
chondria, sometimes  signs  of  diminished  permeability,  or  typhlitis; 
often  a  tumor  may  be  felt  in  severe  cases,  and  as  the  patient  may 
have  a  cachectic  aj)pearance,  causing  suspicion  of  cancer.'  Gall 
stones  may  occlude  the  ileum  suddenly,  after  severe  hepatic  colic, 
followed  by  meteorism,  at  first  limited  to  the  hypo-  and  meso-gas- 
triuni,  with  vomiting,  which  becomes  feculent;  or  the  occlusion  may 
be  preceded  for  a  longtime  by  symptoms  of  diminished  permeability, 
and  repeated  but  temporary  symptoms  of  total  obstruction.'  When  a 
foreign  body  has  passi-d  through  the  pylorus,  it  has  to  traverse  the 
horseshoe  coil  of  the  duodenum,  producing  most  intense  agony  when 
the  substance  is  of  an  elongated  form;  it  is  liable  to  be  arrested  here, 
but  in  most  instances  j)asses  outward,  and  there  is  then  nothing  to 
obstruct  it  until  it  reaches  near  the  ileo-csecal  valve;  but  it  may 
become  arrested  in  any  part  of  its  course  along  the  small  bowels. 
The  symptoms  induced  are  very  vague  and  uncertain,  and  give  no 
evidence  of  either  the  presence  or  sitiuition  of  the  foreign  body; 
they  may  consist  of  those  of  acute  and  chronic  enteritis,  cajcitis,  and 
colitis,  and  even  peritonitis."^  Ordinarily  they  e.xcite  symptoms  of 
partial  obstruction,  and  may  give  rise  to  a  constriction  by  cica- 
tricial bands  or  chronic  peritonitis.'  If  the  obstruction  is  acute, 
administer  oi)ium  at  once,  and  in  full  doses;  if  chronic,  and  the 
symj)toms  of  increasing  obstruction  of  the  passage  grow  more  severe, 
1  0.  Lficlitenstern.  2  a.  Poland. 


396  OPERATIVE  SURGERY. 

give  doses  of  castor  oil,  or  calomel,  and  enemata  of  cold  water. ^ 
Gentle  but  persistent  rubbing  and  kneading  of  the  bowels,  with 
change  of  position,  has  frequently  proved  successful  in  dislodging  the 
obstruction  and  even  overcoming  an  intussusception. "-^  Operative 
interference  is  justified  only  when  three  or  four  days  have  passed 
without  any  relief  from  ordinary  means,  the  constipation  being 
complete,  and  vomiting  of  fascal  matter  continuing,  because  it  af- 
fords a  greater  chance  for  the  preservation  of  life  than  the  ordinary 
means  ;^  laparotomy  should  then  be  unhesitatingly  performed,^  for 
many  cases  of  intestinal  obstruction  undoubtedly  prove  fatal,  which, 
by  timely  operative  interference,  would  result  favorably.^  If  the  ob- 
struction is  not  defined,  the  opening  may  be  made  in  the  right  groin  ^ 
by  an  incision  in  tlie  course  of  Poupart's  ligament,  3  (Fig.  352);  the 
peritoneum  being  opened,  draw  the  lower  portion  of  the  ileum  into 
the  wound  and  attach  it  to  the  margins  of  the  skin  by  wire  sutures 
and  open  it  between  them;  there  is  a  possibility  that  the  obstruction 
will  in  time  be  relieved  tlu'ourrh  this  artificial  anus. 


CHAPTER  XXXVII. 

THE    CiECUM;    THE    COLON. 

I.    THE   C^CUM. 

The  cjECum  is  the  most  capacious  portion  of  the  large  intestines, 
being  about  two  and  a  half  inclies  in  length  and  breadth. 

It  consists  of  a  large  pouch,  occupying  the  right  iliac  region,  where  it  is  re- 
tained in  position  by  a  fold  of  peritoneum  reflected  in  front,  and  by  an  attach- 
ment of  loose  connective  tissue,  though  the  peritoneum,  by  doubling  posteriorly, 
sometimes  renders  the  caicum  less  tixed  than  ordinarily;  the  lower  extremity 
curves  Inwardly  and  backwards,  and  is  abruptly  reduced  into  a  worm-like  pro- 
longation, the  vermiform  appendix,  four  or  five  inches  long,  thick  as  a  goose 
quill,  of  narrow  calibre,  usually  somewhat  coiled  and  retained  by  a  fold  of 
peritoneum." 

1.  Wounds  of  the  cajcum  are  frequently  recovered  from,  even 
when  projectiles  pass  directly  through  its  cavity.  This  compara- 
tive immunity  is  due  largely  to  the  situation  of  the  cascuin  in  the 
lower  part  of  the  abdominal  cavity,  and  only  partial  investment  by 
the  peritoneum.  The  diagnosis  depends  upon  the  direction  of  the 
weapon  or  missile,  and  the  discharges  from  the  wound.  The  treat- 
ment is  expectant,  consisting  of  rest,  anodynes  sufficient  to  relieve 
pain,  cold  at  first  to  prevent  inflammation,  followed  by  poultices,  and 
if  pus  forms,  evacuation. 

1  0.  Leichtenstern.       2  j.  Hutchinson.       3  A.  Poland         *  J.  Ashurst,  Jr. 
6  J.  Hilton.  6  E.  Nelatou.  "  J.  Leidy 


THE  C^CUM.  397 

2.  Perforation  of  the  appendix  vermiformis  ^  frequently  fol- 
lows the  loilgiiient  of  fort'i;.Mj  lju<lie-»  in  this  tiihe,  as  grape-seeds,  or 
even  concrete  mucus ;  the  perforation  mav  allow  the  l)ody  to  escape 
directly  into  the  peritoneal  cavity,  when  fatal  collapse  immediately 
ensues;  more  frequently  inflammation  is  set  up,  which  results  in  the 
formation  of  an  abscess. 

This  abscess  may  terminate  as  follows:  (1)  in  a  dried  mass  of  semi-calcareous 
product;  (2)  the  adhesions  may  suddenly  break  down  and  fatal  extravasation 
into  the  peritoneal  cavitv  follows;  (3)  it  may  open  into  the  iutestine  and  dis- 
charge; (4)  it  may  penetrate  the  cellular  tissue  behind  the  caecum,  and  pass  up- 
ward behind  the  colon,  or  downwards  towards  Poupari's  ligament,  where  it  may 
find  an  opening  at  the  anterior  superior  process  or  under  the  ligament;  the  per- 
foration sometimes  takes  place  directly. 

The  symptoms  2  depend  upon  the  varying  conditions  of  its  progress, 
but  in  general  the  formation  of  an  abscess  would  be  indicated  by 
the  following  signs:  after  some  irregularity  of  the  bowels,  either 
diarrhcea  or  constipation,  generally  the  latter,  and  perhaps  after 
more  than  wonted  exertion,  severe  pain  comes  on,  in  many  cases 
suddenly,  in  the  right  iliac  fossa;  the  pain  may  be  confined  to  this 
spot,  and  be  accompanied  by  excessive  tenderness,  radiating  over 
the  abdomen,  and  be  very  quickly  followed  by  collapse,  and  signs  of 
general  peritonitis,  as,  extremely  anxious  countenance,  sunken  eye, 
cold  extremities,  distended  and  tympanitic  abdomen,  clammy,  partial 
sweats,  failinir  pulse,  and  death  in  a  few  hours;  or  the  tenderness 
and  pain  in  the  neiLdiborhood  of  the  caecum  are  accompanieil  with 
fullness,  and  slight  dullness  in  percussion;  the  skin  is  hot,  the  tongue 
slightly  furred,  pulse  often  compressible  and  somewhat  excited;  local 
peritonitis  is  set  up  in  connection  with  ulceration  or  inflammation  of 
the  coats  of  the  Cfecum.  Exploration  by  the  rectum  sometimes  en- 
ables the  finger  to  detect  the  tumor,  and  determine  its  location. 

Resolution  may  now  occur  with  gradual  subsidence  of  all  the  symptoms,  or 
the  fullness,  tenderness,  and  pain  may  continue,  and  a  more  detined  tumor  be- 
come perceptible,  which  may  at  any  time  perforate  the  peritoneum  and  prove 
fatal,  or  open  into  the  intestine,  or  may  gradually  distend  the  iliac  fossa  and 
approach  the  surface. 

The  treatment  must  be  perfect  quiet,  castor  oil  to  remove  irritat- 
ing matters  from  the  bowels,  followed  b}'  opium  to  relieve  pain,  and 
poultices  to  the  tumor  to  hasten  the  process  of  the  formation  of 
thick  abscess  walls  and  bring  pus  to  the  surface.  The  abscess  must 
be  opened  as  soon  as  pus  is  detected,  and  as  early  as  the  eighth  day 
if  pus  is  not  detected,  and  the  disease  has  steadily  progressed  up  to 
that  time  ;  ^  longer  delay  is  dangerous,  and  at  this  period  the  abscess 
walls  have  commonly  caused  firm  adhesions  of  the  peritoneum. 
1  S.  0.  Habershon;  G.  Lewis.      2  G.  Lewis;  S.  0.  Habershon.     »  W.  Parker. 


398  OPERATIVE  SURGERY. 

It  is  safe  alwa^'s  to  explore,  when  there  is  a  doubt,  with  the  finest  aspirating 
needle,  or  the  hypodermic  syringe;  if  pus  is  discovered,  the  abscess  may  be 
opened  by  the  sharp-pointed  bistoury  entered  at  the  place  of  exploration. i 

The  fornaal  operation  ^  is  as  follows :  Make  an  incis-ion  five  or  six 
inches  in  lengtli,  if  the  swelling  is  large  and  pus  has  not  been  de- 
tected, commencing  an  inch  internal  to  and  above  the  anterior  supe- 
rior spinous  proce^^s  and  extending  towards  the  pubes  3  (Fig.  352); 
continue,  the  dissection  through  the  several  layers  of  the  abdominal 
wall;  raising  them  cautiously,  and  with  a  director,  if  necessary  until 
the  abscess  wall  is  reached ;  introduce  an  exploring  needle,  and  if  pus 
is  found,  puncture  the  abscess.  If,  after  dissecting  down  to  the  peri- 
toneum, pus  is  not  formed,  the  wound  may  be  left  open  and  the  ab- 
scess will  subsequently  discharge  through  this  wound.  The  abscess 
should  be  cleansed  twice  daily  with  carbolized  water,^  and  the  wound 
should  be  allowed  to  heal  by  granulations.  It  may  be  necessary  to 
apply  a  truss  for  some  time,  owing  to  a  tendency  in  some  cases  to 
hernia.^ 

3.  Caecal  abscess  *  may  result  from  the  extension  of  inflamma- 
tion of  its  internal  coat  or  by  the  ulceration  and  perforation  of  the 
walls. 

In  consequence  of  the  angular  course  which  the  axis  of  the  intestines  takes  at 
this  point,  the  cacum  acts  as  a  natural  resting-place  for  the  food  as  it  passes 
through  the  intestinal  canal;  normally  composed  faces  maybe  here  retained 
sufficiently  long  to  become  hardened,  or  even  converted  into  true  fascal  calculi; 
these  masses  and  indigestible  substances,  swallowed  in  the  food,  such  as  kernels 
of  grain,  pins,  pieces  of  bone,  may  collect  in  the  ciBcum,  where  they  act  as  irri- 
tants to  the  mucous  membrane  and  excite  inflammation,  and  ultimately  produce 
ulceration  so  deeply  as  to  perforate  the  bowel. 

If  the  ulceration  is  rapid,  extravasation  may  take  place,  followed 
by  fatal  peritonitis.  The  attack  occurs  suddenly,  without  premoni- 
tory symptoms,  or  may  be  preceded  by  constipation,  dull  pain  in  the 
abdomen,  colic,  and  other  symptoms  of  derangement ;  the  immediate 
attack  is  ushered  in  by  severe  pain,  limited  to  the  right  side  of  the 
abdomen,  increased  by  motion,  even  in  breathing,  and  aggravated  to 
its  greatest  intensity  by  pressure  upon  the  right  inguinal  region  ; 
palpation  reveals  a  tumor,  composed  partly  of  impacted  fteces,  and 
partly  of  inflammatory  exudation;  the  percussion  note  is  dull,  or  at 
least,  dull  tympanitic,  and  the  movements  of  the  right  thigh  are 
painful.  The  patient  frequently  becomes  typhoid,  and  the  disease 
is  often  mistaken  for  typhoid  fever.  The  treatment  should  be  rest, 
castor  oil  to  remove  all  irritating  matters  from  the  cjecum,  then  opium 
to  relieve  pain  and  restlessness,  and  poultices  to  hasten  the  approach 
of  the  pus  to  the  surface ;  the  swelling  should  be  explored  with  a 
fine  aspirating  needle,  or  common  grooved  needle,  or  hypodermic 
1  G.  Buck.  ^  H.  Hancock;  W.  Parker.  3  l.  Weber.  •»  W.  Leube. 


THE   CECUM. 


399 


syringe;  if  pus  is  found,  open  the  abscess  with  a  sharp-pointed  l)is- 
toury,  at  that  point,  or  by  free  incision.  If  the  swelling  fill  the  iliac 
fossa,  and  no  pus  is  found,  operate  as  in  abscess  of  the  appendix, 
and  if  pus  is  still  not  found,  keep  the  wound  open  to  favor  the  escape 
of  pus  when  it  is  formed. 

4.  Intussusception  assumes  two  principal  forms  in  tliis  region; 

(1)  iico-i'olic,  the  passage  of  tin;  ileum  through  the  ileo-cajcal  valve; 

(2)  ileo-ca?cal,  the  i)assage  of  the  ileum  and  cieeum  into  the  colon; 
the  foruier  is  very  rare,  the  latter  tlie  most  common,  especially  in 
childliood  and  during  the  first  ycar.^ 

These  iiivaf;inations  more  often  run  a  chronic  course,  and  are  (Ustinguished 
from  those  of  tlie  small  iutestiues  by  tlie  prominence  of  tenesmus,  wliicli  is  rarely 
present  in  any  marked  (lejj;ree  where  the  small  intestine  only  is  implicated;  by 
the  greater  size  and  lixatioii,  and  different  site  of  the  sausage-like  tumor,  uliicfi, 
if  large,  generally  occupies  the  left  side  of  the  hypogastric  or  left  iliac  region; 
by  the  luemorrhage,  which,  instead  of  being  copious,  is  often  little  more  than  a 
scanty  admixture  scarcely  sufficient  to  tinge  the  mucus  passed  from  the  bowels 
with  violent  and  frequent  straining;  by  tlie  degree  of  obstruction  which  seems 
to  be  reall}'  absent  owing  to  the  patulous  state  of  the  axis  of  invagination;  by 
the  presence  in  the  more  marked  and  protracted  cases  of  the  invagination  ia 
the  rectum. - 

Tlie  tumor  is  rarely  discovered  in  the  region  of  the  cajcum,  owing 
to  its  small  size,  want  of  lirmness,  and  its  rapid  progress  along  the 
colon,  ret\dered  easy  by  tlie  great  mobility  of  the  caacum;  nor  is  it 
easily  detected  when  it  occupies  either  colic*flexure,  particularly  the 
right,  wliere  it  will  be  overlaid  by  the  liver;  more  often  it  is  found 
along  the  course  of  the  descending  colon,  as  an  elongated  swelling 
somewhat  movable  from  side  to  side,  frequently  becoming  harder 
and  more  prominent  during  a  paroxysm  of  , 

pain;  the  linger  in  the  rectum  may  detect 
the  tumor  and  define  the  ileo-cecal  valve, 
and  if  the  other  hand  meantime  is  applied 
to  tlie  abdomen,  the  continuity  of  the  rec- 
tal and  abdominal  tumor  may  be  deter- 
mined.* 


The  post-mortem  appearances^ of  fatal  ileo-ca?- 
cal  intussusception  were  as  follows  (I'lg.  370):  the 
descending  colon  was  enormously  enlarged  and 
full ;  the  sigmoid  tfexure  was  distended  and  made 
a  great  curve  nearly  to  the  right  side  of  the  ab- 
domen;  the  distended  transverse  colon,  thrown 
into  transverse  folds,  could  be  traced  to  the  right 
side  of  the  median  line  ;  tlie  ileum,  ciecum,  and 
ascending    colon    were    entirely   intruded,    and  riG.  3i0. 

pushed  into  the  descending  colon,  descending  into  the  rectum  wiihjn  a  few 
1  O.  l.eichtenstern.      2  \\\  Brinton.       3  n,  b.  Sands.        *  S.  0.  Habershon. 


400  OPERATIVE  SURGERY. 

inches  of  the  anus;  on  opening  the  rectum  and  sigmoid  flexure,  the  termina- 
tion of  the  intussuscepted  portion  was  found  to  be  ahiiost  blacl\.  the  apex  very 
tense  and  its  opening  marked  by  a  tissure  caused  by  the  contraction  (if  the  me- 
sentery; turning  aside  the  bowel,  it  was  found  to  be  convex  and  twisted,  from 
the  dragging  of  the  mesentery',  and  at  the  concave  side  was  a  large  irregular 
ulcer  at  the  most  tense  portion;  there  was  general  peritonitis,  due  to  perfora- 
tion of  an  ulcer  in  the  sigmoid  flexure. 

The  treatment  is  the  same  as  ileum  invaijination,  to  which  is 
added  injections  of  air  and  water.  The  distention  of  the  lower 
bowel  must  l:)e  carried  to  the  fullest  extent  short  of  rupture,  and 
should  be  undertaken  early,  before  adhesions  have  formed;  if  water 
is  used,  place  the  patient  on  the  back,  in  bed,  or  if  a  child  on  the  lap 
of  the  nurse;  elevate  the  hips  45°,  to  secure  the  aid  of  gravitation  ; 
provide  lukewarm  water,  and  with  the  common  bulbous  syringe,  or, 
better,  the  fountain  syringe,  inject  it  gently  until  the  abdomen  is 
somewhat  distended;  now  carry  the  finger  gently  but  firmly  over  the 
abdominal  walls  along  the  tlirection  of  the  colon,  in  order  to  force 
the  liquid  upward  against  the  intussusception  ;  if  the  water  is  dis- 
charged, the  injection  may  be  several  times  repeated.  ^  If  water 
fail,  inflation  may  be  resorted  to,  which  produces  a  more  equable 
and  effective  distention;  the  common  bellows,  with  a  tube,  is  effi- 
cient;'- or  carbonic  acid  gas  may  be  employed,  as  obtained  from 
bottles  charged  with  the  gas  in  the  shops;  by  inversion  a  powerful 
current  may  be  conducted  through  the  tube  of  a  rubber  syringe.^ 
The  operation  of  laparotomy,  in  this  form  of  invagination,  should  be 
undertaken  as  a  last  resort,  but  the  delay  should  not  be  so  great  as 
to  endanger  the  integrity  of  the  bowel. 

II.    THE  COLON". 

The  colon  ascends  from  the  caecum  in  the  right  iliac  region  in  front 
of  the  right  kidney  to  the  under  part  of  the  liver,  the  ascending 
colon ;  it  then  crosses  through  the  upper  boundary  of  the  umbilical 
region  to  the  left  hypochondriac  region,  the  transverse  colon,  where 
it  forms  an  angle  and  descends  in  front  of  the  left  kidney  to  the  left 
iliac  region,  the  descending  colon  ;  here  it  forms  an  S-like  convolu- 
tion, the  sigmoid  flexure,  and  enters  the  pelvis  as  the  rectum. ^ 

1.  Wounds  of  the  large  intestine^  are  less  fatal  than  those  of 
the  small,  owing  to  the  fact  that  there  is  less  liability  in  wounds  of 
this  portion  of  the  intestinal  canal  to  extravasation  of  the  fajcal  con- 
tents into  the  peritoneal  cavity;  this  is  due  to  the  disposition  of  the 
muscular  coat,  and  the  firm  attachments  by  which  the  gut  is  secured, 
which  tend  to  preserve  that  parallelism  between  the  wounds  in  the 
parietes  and  in  the  bowel,  and  that  apposition  of  the  intestinal  and 

1  J.  L.  Smith.  2  D.  Greig.  3  j.  Leidy.  4  s.  D.  Gross. 


THE   COLON.  401 

parietal  .surfaces  that  are  such  important  safeijiiarils  ;  fnrtlier  favor- 
aljlu  ciMiditions  are  f(juiitl  in  tlie  fads  that  ihi-  colon  is  only  partially 
invesie<l  l)y  the  peritdneuni,  and  injuries  of  its  ascending  and  de- 
scending portions  especially,  do  not  necessarily  je()j)ardize  other  or- 
gans. Tlio-e  wounds  are  generally  attended  by  stenoral  fi^tula, 
which  commonly  close  after  a  time,  without  operati\e  interference, 
reopening  at  intervals  and  then  healing  permanently.  'I'lie  differen- 
tial diagnosis  between  wounds  of  the  large  and  small  intestines  is 
often  very  difficult,  and  sometimes  unattainable.  These  wounds 
often  do  well  without  interference,  arul  enteroraphy  will  seldom  be 
requisite  unless  the  wounded  colon  jirotrudes;  but  there  are  excep- 
tional cases  in  which  exiending  the  external  wound  and  sewing  up 
the  rent  in  the  gut  is  the  only  means  of  preventing  extravasation. ^ 

In  a  considerable  number  of  these  wounds  the  abnormal  communication  be- 
tween the  bowel  and  the  exterior  of  tlie  abdomen  remains  open,  and  constitutes 
an  artificial  or  preternatural  anus;  but  there  is  an  absence,  or  only  slight  devel- 
opment of  the  crescent-shaped  septum  connnonly  formed  in  cases  of  preternatural 
anus  fdllouing  mortilication  of  the  intestine  in  strangulated  hernia.i  As  the 
chief  obstacle  to  the  permanent  closure  of  abnormal  anus  is  the  septum,  which 
prevents  the  contents  of  the  bowel  above  from  reaching  the  calibre  of  the  bowel 
below,  these  lesions  in  which  the  septum  is  slight,  are  more  curable  than  those 
which  follow  strangulated  hernia.  The  treatment,  therefore,  depends  upon  the 
features  of  each  case;  if  the  opening  is  small,  keep  the  parts  clean,  and  restrain 
the  escape  of  faeces  or  food  through  the  oriike  by  the  application  of  gentle  pres- 
sure, and  closure  will  frequently  occur;  if  the  wound  shows  no  tendency  to  close 
and  the  patient  refuse  operative  interference,  place  a  compress  of  linen  in  the 
opening  with  a  larger  pad  over  it,  and  apply  a  truss  to  retain  dressings. 

2.  Simple  stricture  of  the  colon  -  results  from  the  cicatrization 
after  ulceration  of  the  mucous  membrane;  the  stricture  may  be  a  mere 
ring,  or  it  may  occupy  several  inches  of  the  bowel.  The  symptoms 
may  for  a  long  time  be  vague,  inconclusive,  and  even  misleading; 
occasionally  the  symptoms  come  on  quite  suddenly,  but  in  general  the 
patient  suffers  for  weeks,  or  months,  or  years,  with  occasional  at- 
tacks of  colicky  pain,  associated  it  may  be  with  more  or  less  consti- 
pation, or  even  diarrhoea;  when  the  case  is  free  from  complications 
its  progress  is  essentially  chronic;  but  sooner  or  later  symptoms  ap- 
pear which  indicate  impassable  stricture  ;  namely,  insuperable  consti- 
pation, painful  peristalsis  coming  on  j)eriodically,  and  often  rendering 
itself  auilibie  by  borborygmi,  and  visible  through  the  abdominal 
walls;  abdominal  fullness  and  tmcasiiiess.  followed  by  nausea  and 
vomiting.and  finally  the  ejection  of  stercoraceous  matters.  It  is  diffi- 
cult to  determine  the  seat  of  stricture,  and  the  only  guides  are  dis- 
tention of  the  bowels  above  and  collapse  below;  thus  fidlncss  and 
dullness  in  the  course  of  th(    cajcum  and  ascending  colon  indicates 

>  G.  A.  Otis.  2  J.  S.  Bristowe. 

26 


402 


OPERATIVE  SURGERY. 


stricture  at  the  hepatic  flexure;  the  same  conditions  of  the  transverse 
colon  point  to  stricture  at  the  splenic  flexure,  and  the  like  state  of 
the  descending  colon  locates  stricture  at  the  sigmoid  flexure. 

The  flexible  rubber  tube  i  now  renders  it  possible  to  fully  ex- 
plore the  colon  as  far  as  the  caecal  portion,  from  the  anus,  and 
test  its  calibre  (Fig.  371) :  different  sizes  may  be  used  to  determine 
the  calibre :  the  tube  must  be  introduced  very  gently,  but  being 
very  yielding,  no  harm  can  be  done  unless  unnecessary  force  is 
employed. 

The  treatment  is  perfectly  fluid  or  pultaceous  food, 
easy  of  digestion,  and  well  masticated;  relief  of  consti- 
pation, by  simple  non-purgative  enemata ;  avoidance  of 
purgatives.  If  the  stricture  is  at  any  point  below  the 
splenic  flexure,  dilatation  may  Vje  attempted  with  the 
rectal  dilator  and  explorer  (Fig.  371).^ 

The  dilators  used  are  manufactured  out  of  pure  rubber,  with  a 
canal  running  tlie  whole  length,  and  gradually  increasing  in  size 
by  an  eighth,  from  a  quarter  of  an  inch  to  an  inch  in  diameter; 
each  dilator  is  fitted  with  a  gum  sheath  of  corresponding  dimen- 
sions. The  points  of  the  dilators  taper  for  an  inch  and  a  half,  or 
two  inches,  conically:  the  whole  length  of  the  sheath,  both  in- 
side and  outside  the  bowel,  or  any  portion  of  it,  may  be  tilled 
with  water:  in  the  latter  case  a  thread  of  silk  is  to  be  twisted 
around  the  dilator  at  any  point  that  it  may  be  desirable  to  limit 
the  distention. 

The  method  of  introducing  the  dilator  is  as  follows:  Place  the 
patient,  reclining  on  his  left  side,  upon  an  ordinary  operating- 
FiG.  .371.  table,  the  thighs  flexed  and  the  buttocks  just  overhanging  the 
lower  edge.  The  smallest-sized  instrument  is  smeared  with 
grease,  and  its  point  inserted  into  the  anus  and  gently  pushed  onward  in  the 
following  manner:  the  right  hand  grasps  the  dilator  close  to  the  anus,  and  the 
whole  perineum  is  to  be  pressed  upwards,  which  will  advance  the  point  of  the 
instrument;  the  left  hand  now  steadies  it,  while  the  right  is  slid  downwards 
for  a  lower  hold,  the  perineum  of  course  settles  with  it;  the  dilator  is  again 
pushed  forward  in  the  same  manner  until  the  obstruction  is  passed;  this  may  be 
greatly  facilitated  by  sinking  the  fingers  of  the  left  hand  deep  into  the  left  iliac 
region,  and  drawing  upwards,  as  though  an  effort  was  being  made  to  stretch 
out  the  sigmoid  flexure,  which  pressure  is  maintained  at  the  same  time  upon 
the  dilator  in  the  manner  described;  another  practical  point  of  prime  import- 
ance is  to  employ  an  abundant  stream  of  water,  projecting  it  through  the  con- 
duit of  the  in>trument  as  warm  as  can  be  comfortably  borne,  whenever  its 
point  is  arrested  from  any  cause:  the  water  flowing  from  the  di»ial  aperture  will 
distend  the  bowel,  efface  its  folds,  and  break  down  any  hardened  fa-cesthat  may 
exist,  obstructing  the  ascent  of  the  dilator;  while  the  operator  is  engaged  with 
the  dilator,  an  assistant  may  manage  the  syringe  and  throw  in  the  water  in  such 
quantities  as  may  be  needed;  it  must  be  borne  in  mind,  however,  that  no  great 
volume  should  be  used  at  once,  otherwise  the  bowel  will  be  excited  to  energetic 
contraction,  and  compel  the  dilator  to  be  withdrawn  before  it  has  been  properly 
1  P.  S.  Wales. 


THE   COLON.  403 

lodped.  In  preliminan*  trials  the  dilator  may  be  permitted  to  remain  two  or 
three  ininiites,  and  afterwards,  when  greater  tolerance  is  established,  a  longer 
stav  mav  be  allowed.  After  several  introductions  of  one  size  of  the  dilators, 
perhaps  seven  or  eight,  the  next  largest  may  be  taken,  and  so  on  until  the 
stricture  has  been  sutflciently  expanded.  The  application  of  the  instrument  may 
be  repeated  twice  or  thrice  a  week,  according  to  circumstance^,  such  as  the  irri- 
tability of  the  rectum,  temperament  of  the  individual,  and  intercurrent  attacks 
of  diarrhoea  or  other  trouble. 

If  the  stricture  becomes  impassable,  an  operation  must  be  under- 
taken for  its  relief;  this  consists  in  opening  the  colon,  colotoiny,  at  a 
suitable  point,  and  the  formation  of  an  artificial  anus.  If  the  stricture 
is  in  the  ascending  or  transverse  colon,  the  operation  should  1^  on 
the  right  side,  and  if  at  the  sigmoid  flexure,  on  the  left  side. 

3.  Colotomy,  section  of  the  colon,  for  the  relief  of  obstruction 
of  the  inte>tine  by  stricture  or  morbid  growths,  should  be  performed 
in  the  lumbar  region,^  for  the  purpose  of  opening  the  colon  on  the 
posterior  surface,  where  it  is  uncovered  by  the  peritoneum. 

The  important  anatomical  features  of  this  region  are  as  follows:  It  is  a  quad- 
rilateral space  bounded  alxive  by  the  last  rib.  below  by  the  iliac  crest,  behind  by 
the  longi<simus  dorsi  and  sacro  lumbalis  muscles,  and  anteriorly  by  a  vertical 
line  drawn  from  the  centre  of  the  crest  of  the  ilium  to  the  last  rib:  in  this  space 
the  colon  lies  in  front  of  the  kidney  and  separated  from  it  by  adipose  tissue; 
the  centre  of  this  space  corresponds  with  the  fascia  transversalis,  and  is  separ- 
ated from  the  qiiadratus  lumlwrum  muscle  by  some  adipose  tissue;  anteriorly 
and  externally  the  colon  is  in  contact  with  the  small  intestines,  and  its  distance 
from  the  spine  varies  according  as  it  is  contracted  or  distended;  if  contracted, 
the  space  between  the  peritoneal  folds  behind  is  slight,  but  when  distended,  the 
portion  uncovered  by  peritoneum  is  increased. 2  The  conclusion  as  to  the  pre- 
cise location  of  the  colon,  based  on  more  than  fifty  dissections,  i«,  that  it  is  al- 
ways normally  situated  half  an  inch  posterior  to  the  centre  of  the  crest  of  the 
ilium,  or  a  point  midway  between  the  anterior  and  posterior  spinous  processes.' 
Before  operating  it  is  well  to  mark  out  the  two  processes,  then  find  the  centre 
point  between  them  and  draw  a  vertical  line  full  half  an  inch  behind  this  centre* 
spot.  By  attention  to  these  rules,  the  operation  will  not  be  found  very  ditticult, 
and  when  the  gut  is  much  distended  and  the  patient  thin,  nothing  can  well  be 
easier;  this  is  not  the  case  when  the  bowel  is  collapsed  and  the  patient  muscular 
or  fat.  The  numerous  failures  to  find  the  colon  are  due  to  the  fact  that  it  has 
been  looked  for  too  far  from  the  spine. ^ 

When  the  bowel  is  collapsed  there  is  an  advantage  in  distending  it  bv  an  in- 
jection of  warm  water  or  of  air.^  This  must  be  done  when  the  patient  is  under 
the  influence  of  an  anaesthetic;  distention  by  air  is  most  cleanly  and  manage- 
able; to  retain  the  injection  the  rectum  must  be  plugged  with  wet  lint,  re- 
tained by  the  finger  of  an  a$.<istant.°2 

Proceed  as  follows,*  the  operation  being  on  the  left  side:  Place 
the  patient  on  the  right  side,  with  a  pillow  under  the  loin,  that  the 
left  loin  may  be  thrown  into  greater  prominence;  make  an  incision 
four  inches  long,  somewhat  oblirpiely  between  the  crest  of  the  ilium 
1  M.  Callisen;  M.  .imussat.       ^  £.  Mason.       «  W.  Allingham.       *  C  Heath. 


404 


0  PER  A  TI VE  S  UR  GER  Y. 


and  the  last  rib,  half  of  the  incision  being  on  each  side  of  the  ver- 
tical line  marked  out  (Fig.  372);  the  direction  of  the  incision  has  been 
vertical,^  transverse, ^  and  oblique  ;  ^  but  the 
"«  slightly  oblique  incision,  running  parallel  to  the 
last  rib,  should  be  preferred;  divide  the  skin, 
subcutaneous  fat,  the  external  oblique  and  latis- 
simus  dorsi  muscles,  thus  exposing  the  internal 
oblique;  divide  it  the  whole  length  of  the  wound 
until  the  fascia  luniborum  conies  into  view,  which 
carefully  divide  on  a  director;  the  loose  fat  is 
now  exposed  about  the  kidney  and  colon  in  the 
anterior  part  of  the  wound,  and  the  edge  of  the 
quadi'atus  luniborum  behind;  keep  the  edges  of 
the  wound  open  with  spatulae,  and  displace  the 
fat  with  the  finger  and  seek  for  the  bowel;  in  cases  of  obstruction 
with  distention,  there  is  no  trouble  in  doing  this,  the  bowel  present- 
ing at  the  wound  covered  only  by  fascia  transversalis;  this  fascia 
varies  in  thickness  in  different  cases,  and  has  sometimes  been  mis- 
taken for  peritoneum;  if  the  bowel  be  empty,  tear  through  the 
fascia  transversalis  carefully  with  the  finger-nail  just  in  front  of  the 
quadratus  lumborum,  introduce  the  forefinger,  and  hook  the  intes- 
tine; if  this  does  not  succeed,  turn  the  patient  over  upon  his  back 
and  the  bowel  will,  in  all  probability,  fall  on  the  finger ;  bring 
the  bowel  into  the  wound,  roll  it  round  and  expose  the  posterior 
surface,  which  is  generally  uncovered  by  peritoneum,  and,  when 
the  bowel  is  distended,  this  surface  is  much  larger;  with  a  large 
curved  needle  pass  a  stout  silk  thread  through  the  skin  to  one  side 
of  the  mark,  across  the  bowel,  and  again  through  the  skin  at  a  cor- 
responding jioint  on  the  other  side  of  the  mark,  repeating  the  pro- 
ceeding at  the  other  end  of  the  incision;  thus  the  colon  is  held  to 
the  margins  of  the  wound  before  being  opened; 
make  a  transverse  incision  into  the  bowel  be- 
tween the  threads,  and,  the  finger  being  intro- 
duced, the  two  loops  can  be  drawn  out,  and, 
on  dividing  them,  four  threads  only  are  re- 
quired to  be  tied  to  fix  the  bowel  to  the  wound; 
close  the  rest  of  the  incision  on  each  side  of 
the  bowel  by  ordinary  sutures  (Fig.  373). 

The  colon  may  be  recognized^  by  (1)  its  distention  and  greenish  iuie;  (2)  its 
peculiar  bands;  (3)  its  quiescence  during  respiration  wiiile  tiie  small  intestines 
move. 

The  after-treatment^  differs  in  no  respect  fi'om  that  of  any  other 

wound;  it  may  be  covered  at  first  with  lint  spread  with  oxide  of  zinc 

i  M.  Callisen.  2  m.  Amussat.  3  m.  Baudens.  *  E.  Mason. 


Fio.  373. 


THE  RECTUM.  405 

ointment,  and  with  carbolic  acid;  this  is  changed  when  soiled  ;  after 
the  bowels  have  been  moved  freely,  a  pad  of  oakum  may  be  placed 
over  the  opening  and  a  bandaj^e  applied;  the  stitches  confining  the 
bowel  to  the  integument  may  be  removed  on  the  fourth  or  fifth  day, 
or  be  left  to  separate;  if  the  case  progress  favorably,  the  patient 
may  sit  up  in  bed  on  the  fifth  or  sixth  day;  if  fajcal  matters  pass 
down  into  tlie  rectum  below,  an  enema  will  remove  them.  If  the 
disease  for  which  the  operation  is  performed  is  recovered  from,  the 
artificial  anus  frecpiently  closes,  proving  that  the  effort  to  close  the 
opening,  when  no  longer  required,  should  be  attempted.^ 

4.  Cancer  of  the  colon  is  most  frequent  in  the  sigmoid  flexure. 
These  growths  are  almost  exclusively  gland  cancers ;  the  prolifera- 
tion proceeds  from  the  large  glands  of  the  large  intestines,  and  grow 
in  the  shape  of  tortuous  and  branched  tubes;  the  calibre  of  the  gland 
is  often  maintained,  but  it  fills  with  mucus,  and  the  cylinder  cells 
may  maintain  their  form  and  become  very  large;  at  first  the  muscu- 
lar coat  of  the  intestine  is  hypertrophied,  but  subsequently  it  is 
also  affected  by  the  ulceration,  which  begins  early.-  The  symptoms 
are  those  of  chronic  obstruction,  to  which  are  added  the  cancerous 
cachexia  and  the  detection  of  a  tumor.  The  treatment  is  colotomy. 
Though  the  operation  is  in  no  sense  curative,  it  undoubtedly  pro- 
longs life  and  renders  it  comfortable.'  To  derive  its  full  value,  the 
operation  .should  be  performeil  at  an  early  period,  before  the  stric- 
ture becomes  impassable.  If  it  is  delayed  until  the  vital  powers  are 
worn  out  by  long-continued  suffering,  or  until  absolute  constipation 
occurs,  the  shock  may  be  so  great  that  life  is  forfeited. 


CHAPTER    XXXVIII. 
THE    RECTUM. 

The  rectum  coinmences  opposite  the  left  sacro-iliac  articulation, 
and  is  directed  at  first  obliquely  downwards,  and  from  left  to  right, 
to  gain  the  middle  line  of  the  sacrum  ;  it  then  changes  its  direction 
and  curves  forward  in  front  of  the  lower  ])art  of  the  sacrum  and  the 
coccyx,  and  opposite  the  prostate  gland  turns  backwards  and  down- 
wards to  reach  the  anus;  it  is  from  six  to  eight  inches  in  leni^th, 
and  is  rather  narrower  than  the  sigmoid  flexure  at  its  upper  end.  but 
becomes  dilated  into  a  large  ampulla  or  reservoir  immediately  above 
the  anus.'* 

1.  Exploration  of  the  rectum  may  be  with  the  fin-^er,  liand, 
1  E.  Mason.     -  T.  Billroth.     3  x.  B.  Cuiling;  Sir  J.  Paget.      *  <iiiaiii's  Anat. 


406  OPERATIVE  SURGERY. 

or  speculum.  In  exploring  with  the  finger,^  place  the  patient  on  the 
side,  with  the  knees  well  drawn  up;  lubricate  the  finger  well  with  oil, 
and  pass  it  gently  through  the  anus,  avoiding  any  rude  movements; 
by  pushing  with  force  and  burying  the  knuckle  in  the  perineum,  a 
distance  of  four  or  five  inches  from  the  anus  may  be  reached;  if 
now  the  patient  bear  down,  the  exploration  may  extend  six  inches. 
Exploration  with  the  hand  ^  must  be  performed  with  great  caution, 
to  avoid  rupturing  the  mucous  membrane  or  other  tissues;  the  pa- 
tient being  fully  anaesthetized,  place  him  on  the  back  with  the  knees 
drawn  upwards;  the  hand  and  arm  being  well  oiled,  give  a  conical 
form  to  the  tips  of  the  fingers,  and  apply  the  palm  of  the  thumb  to 
that  of  the  fingers,  its  tip  placed  between  the  index  and  little  fingers; 
gently  insinuate  the  tips  into  the  anus  with  a  semi-rotatory  motion, 
and  continue  the  process  until  the  hand  is  lodged  in  the  rectmu; 
the  dilatation  of  the  sphincter  should  be  very  gradual,  and  should 
occupy  at  least  five  minutes ;  when  once  through  the  sphincter,  the 
windings  of  the  gut  should  be  followed  by  a  semi-rotatory  movement 
of  the  hand,  and  by  alternate  semiHexing  and  extending  the  fingers; 
in  many  cases  the  hand  can  be  passed  into  the  sigmoid  flexure,  and 
possibly,  in  rare  instances,  into  the  descending  colon  ;  should  the 
hand  meet  with  a  feeling  of  constriction  about  the  junction  of  the  first 
and  second  portions  of  the  rectum,  no  force  on  any  account  should 
be  used  to  overcome  it,  as  this  can  only  be  accomplished  by  ruptur- 
ing the  peritoneum,  which  is  here  reflected  from  the  intes- 
tine. Specula  have  a  limited  value  in  their  application,  and 
when  employed,  anaesthesia  is  a  most  valuable  aid.^  For 
thorough  exploration  place  the  patient,  when  under  the  full 
influence  of  an  auEesthetic,  on  a  table  of  proper  height,  or 
on  a  uterine  chair,  and  in  a  good  light,  the  body  in  the 
prone  position,  with  outspread  arms  and  the  hips  properly 
elevated;  introduce  a  speculum  vaginse,  or  a  similar  form, 
(Fig.  374),  and  elevate  the  posterior  wall;  the  whole  inter- 
FiG.  374.  nal  surface  of  the  rectum  as  high  up  as  its  termination  in- 
the  sigmoid  flexure,  may  be  exposed  to  view.^ 

A  great  variety  of  specula  have  been  introduced  into  practice,  but  those  forms 


Fig.  376. 
1  W.  H.  Van  Buren.  2  G.  Simon ;  W.  J.  Walsham. 


THE  RECTUM. 


407 


have  the  greatest  value  which  contract  and  expand,  as  they  admit  of  easy  in- 
trodtiction,  and  give  ,^^ 

I  lie  largest  ex[)osure  ■ — ° 

of  the  internal  cav- 
ity; the  vaginal 
specula  of  this  kind 
answer  a  good  pur- 
pose; such   are   the 

bivalve  (Fig.   375);  Fig.  379. 

the  trivalve  (Fig.  37G);  the  quadrivalve  (Fig.  377); 
Fk;.  378.  the  irregular  form,  which  may  close  (Fig.  378),  or 

open  (F'ig.  379) ;  ^  or,  the  still  more  compact  and  expansible  instrument  (Figs. 

380,  381);"-  or,  liually,  a  still  more  open  instrument  (Fig.  382). 


Fig.  .380. 


Fig.  381. 


Fig.  382. 


2.  Medication  by  the  rectum  is  chiefly  required  for  the  purpose 
of  j)roc'urin(r  an  evaluation  of  the  bowels,  or  for  administer- 
ing remedies  which  it  is  not  advisable  to  give  by 
the  stomach.  The  common  syringe,  with  barrel 
and  piston  (Fig.  383),  is  now  employed  only  to 
give  small  (quantities  of  fluid,  as  in  administering 
an  anodyne  injection.  For  injections  in  bulk,  and 
for  general  use,  the  rubber  bulbous  syringe^  is 
preferable  (Fig.  384).  Or,  the  apparatus*  may  ^lo.  384. 
consist  of  an  elastic  air-bulb  a,  a  stand  pipe  c,  which  rests 
^  in  the  bowl,  the  pipe  c/,  and  the  nozzle  e  (Fig.  385). 
3g3  The  enema,  though  of  daily  use,  is  rarely 
administered  with  re()uisite  skill,  being  too 
often  intrusted  to  those  ignorant  of  its  nature  and  pur- 
poses ;  it  must  be  accurately  adapted  in  quantity  and 
quality  to  tlie  capacity  and  tolerance  of  the  bowel  and 
l)e  so  administered  as  not  to  pain,  irritate,  or  injure 
the  parts. ^  x\n  enema  consists  of  the  menstruum,  as 
water,  boiled  starch,  mint  tea,  and  the  ingredients, 
which  are  laxative,  stinndating,  anodyne,  or  nutritious; 
the  quantity  used  must  depend  upon  the  effect  desired, 
these  facts  being  borne  in  mind,  namely,  (1)  the  larger 
the  quantity  the  more  promptly  the  bowels  act,  and 
1  J.  C.  Nott.      2  j^.  Bozeman.      8  Davidson.      *  Mattson. 


Fig. 


408  OPERATIVE  SURGERY. 

vice  versa;  (2)  three  times  more  in  quantity  are  required  by  the  rec- 
tum than  the  stomach;  (3)  absorption  by  the  rectum  recjuires  double 
the  time  of  the  stomach.  The  ordinary  injection  is  given  as  follows  : 
inject  the  fluid  through  the  tube  until  all  air  is  expelled;  place  the 
patient  on  the  side,  with  tlie  thighs  flexed  ;  separate  the  nates  and 
gently  insert  the  tube,  passing  it  first  slightly  forward  towards  the 
umbilicus,  then  backward  towards  the  cavity  of  the  sacrum ;  when 
the  tube  has  entered  two  to  three  inches,  force  the  fluid  slowly  into 
the  bowel  until  the  requisite  quantity  is  given ;  withdraw  the  tube 
very  slowlv,  and  if  there  is  any  tendency  to  escape,  press  a  cloth 
firmly  against  the  parts. 

3.  Alimentation  by  the  rectum ^  is  required  in  diseases  of  the 
oesophagus  preventing  swallowing,  and  in  diseases  of  the  stomach 
which  prevent  the  retention  or  ingestion  of  food;  life  may  in  this 
manner  be  maintained  for  long  periods.  The  nutritive  injection 
should  be  composed  of  materials  which  need  no  digestion,  as  milk, 
eggs,  mutton  and  chicken  broths. 

Pancreatic  meat  emulsion  2  should  be  made  as  follows  :  to  five  to  ten  ounces  of 
finely  chopped  meat  add  one  third  of  that  weight  of  tlie  ivesh  pancreas  of  the  ox; 
remove  tlie  fat  and  mix  with  about  five  ounces  of  water,  and  reduce  the  whole 
to  the  consistence  of  a  thick  soup.  Or,  the  following  preparation  may  be  used  : 
crush  or  grind  a  pound  of  beef  muscle  fine,  add  one  pint  of  cold  water,  allow 
it  to  macerate  three  fourihs  of  an  hour,  now  raise  it  to  the  boiling  point  and  let 
it  boil  two  minutes  and  stand. ^ 

The  quantity  used  should  be  three  or  four  ounces  every  four  hours, 
and  it  should  be  tepid.  The  bowels  should  first  be  moved  by  a  laxa- 
tive or  enema;  the  injection  should  be  very  gently  thrown  into  the 
rectum;  at  first  it  may  not  be  retained,  but  by  repetition  and  pressure 
upon  the  anus,  tolerance  is  established;  or  opium  may  be  added  to 
the  enema;  if  at  any  time  the  rectum  becomes  irritable  the  injection 
may  be  carried  to  the  colon;*  as  a  substitute  for  drink,  water  may 
be  thrown  into  the  rectum;  the  rectum  need  not  be  washed  out  be- 
fore each  enema. 

4.  Imperforate  rectum  is  caused  by  a  membranous  partition 
which  may  be  just  within  the  anus  or  an  inch  or  more  above;  it 
varies  in  thickness,  but  is  usually  thin  ;  the  symptoms  are  retention 
of  the  meconium  and  vomiting.  Examination  with  the  finger  or 
probe,  or  a  small  elastic  catheter  or  bougie  determines  its  nature ;  if 
tl^e  membrane  is  thick,  it  may  not  be  possible  to  decide  whether  the 
intestine  is  continuous  above  till  an  incision  is  made,  but  if  it  is  thin 
it  will  bidge  down  upon  the  finger,  especially  when  the  child  cries. ^ 
Delay  the  operation  a  day  or  two,  until  the  meconium  dilates  the 
lower  part  of  the  intestine;  if  the  septum  is  thin,  break  it  down 
1  A.  Flint.      2  \v.  Leube.       3  £.  r.  Peaslee.      4  p.  Barker.      5  T.  J.  Ashton. 


THE  RECTUM.  409 

with  the  end  of  the  little  finger;  if  thick,  puncture  with  a  sharp- 
pointed  bistoury,  the  blade  being  wrapped  with  thread,  and  cau- 
tiously carried  into  the  passage  on  a  grooved  director,  or  along  the 
finger;  enlarge  the  puncture  by  a  crucial  incision;  dilate  with  the 
end  of  the  little  finger,  or  a  dressing  forceps;  pas-s  the  finger,  or  a 
bougie  of  suitable  size,  daily,  for  several  months. 

5.  Absence  of  the  rectum  may  be  jjartial.  which  is  most  com- 
mon,^  or  complete,  the  anus  being  normal.  When  only  partially  ab- 
sent, the  other  portion  usually  terminates  in  a  cul-de-sac,  at  a 
greater  or  less  distance  from  the  surface  of  the  body,  or  it  inay  be 
prolonged  as  a  narrow  tube  or  imperforate  cord,  and  blendeil  with 
adjacent  parts;  if  wholly  absent,  the  canal  may  open  in  some  abnor- 
mal situation.'^  The  diagnosis  is  made  by  examination  with  the  fin- 
ger or  a  bougie.  If  the  occlusion  is  not  thick,  ii  is  only  necessary  to 
incise  the  intervening  tissues,  and  dilate.  If  the  part  is  very  thick 
and  hard,  dilate  the  anus,  if  necessary  add  lateral  incisions;  separate 
the  mucous  membrane,  and  draw  down  the  rectum  ;  cut  off  that  por- 
tion including  the  septum,  and  attach  the  margin  by  suture  to  the 
skin.8  If  the  rectum  is  wholly  absent,  and  the  bowel  cannot  be 
reached  by  dissection,  a  last  resort  is  to  make  an  artificial  anus. 

6.  Laceration  may  involve  the  mucous  membrane  only;  or  all  of 
ihe  coats  of  the  rectum;  incomplete  laceration  is  generally  the  result 
of  the  expulsion  of  hardened  fteces,  and  is  vertical  when  it  results 
from  undue  distention  of  the  anus  during  the  violent  efforts  of  the 
expulsive  muscles,  and  transverse  when  a  fold  of  raucous  membrane 
falls  under  a  mass  of  indurated  fasces  at  the  moment  of  its  forcible 
extrusion;  complete  laceration  occurs  in  parturition,  and  from  ex- 
ternal violence,  as  blows,  the  passage  of  an  injection-pi jk^  or  cath- 
eter, or  foreign  bodies  lodged  in  the  rectum,  or  penetrating  through 
the  anus.  The  treatment  of  incomplete  laceration  consists  in  ])ro- 
tecting  the  wound  from  irritation  by  emollient  enemata,  cleansing 
the  surface,  and  the  aj)plication  of  nitrate  of  silver,  if  healing  does 
not  progress  favorably ;  in  complete  laceration,  it  may  be  possi- 
ble to  close  the  wound  by  suture,  but  if  not,  it  must  be  treated  as 
a  fistula. 

7.  Abscess  near  the  rectum,  if  acute,  appears  as  a  throl)bing 
swelling,  hot  and  })ainfid,  with  fever;  if  subacute,  there  may  be  little 
or  no  pain;  if  it  is  difficult  to  detect  the  presence  of  pus,  owing  to 
the  elasticity  of  the  cellular  tissue  and  its  depth  from  the  surface; 
introduce  one  or  two  fingers  into  the  rectum  and  nuvke  counter  pres- 
sure, by  which  means  fluctuation  is  easily  di.scovered ;  when  ])us  is 
detected,  open  the  abscess  by  puncture;  the  after  treatment  con- 
sists of  poultices,  care  being  taken  to  prevent  the  external   woiuul 

1  G.  Bushe.  2  T.  J.  Ashton.  a  M.  Amus^at. 


410  OPERATIVE  SURGERY. 

healing  before  the  cavity  of  the  abscess,  by  the  insertion  of  tents 
occasionally.^ 

As  a  rule,  however,  to  which  exception  is  rare,  these' abscesses  do  not  heal, 
but  become  tistidous  (Figs.  3!)],  392,  393),  owing  to  the  constant  motion  to 
which  the  healing  part  is  subjected  ijy  the  proximity  of  the  restless  sphincter 
muscle,  and  the  muscular  pouch  of  tlie  rectum,  wliicli  is  continually  varj'ing  in 
volume;  to  guard  against  censure,  warn  the  patient  of  this  contingency  before 
opening  the  abscess.^ 

8.  Stricture  of  the  rectum  is  the  result  of  any  cause  which  in- 
duces a  thickening  and  contraction  of  the  coats  of  the  bowel  in  that 
region,  as  injuries,  specific  or  malignant  disease.  (1.)  Simple  stric- 
ture follows  the  organization  of  the  products  of  inflammation  in  the 
submucous  cellular  tissue  and  muscular  coat;  in  severe  and  long 
continued  cases,  the  fibrous  deposit  is  more  extensive  and  dense,  and 
in  adilition  to  a  very  narrow  contraction  there  is  a  large  amount  of 
thickening  of  the  coats  of  the  bowel,  but  there  may  be  a  considerable 
contraci ion  with  slight  consolidation  of  the  surrounding  tissues;  in 
rare  instances,  the  stricture  is  due  only  to  fibrous  bands  running 
across  the  bowel,  or  it  involves  only  a  portion  of  its  circumference; 
the  extent  of  bowel  affected  vai-ies  from  one  or  two  lines  to  half  an 
inch,  an  inch  and  a  half,  or  even  three  or  four  inches;  the  bowel 
above  is  generally  more  or  less  dilated,  with  increase  of  its  muscular 
coat,  while  the  mucous  membrane  is  vascular,  thickened,  or  even 
ulcerated.^  Its  usual  location  is  within  two  or  three  inches  of  the 
anus,  and  it  can  readily  be  detected  by  the  finger;  rarely,  it  is  found 
higher  up,  even  in  the  sigmoitl  flexin-e.^  The  symptoms  are  refer- 
rible  directly,  or  indirectly,  to  the  mechanical  obstruction  to  the  func- 
tion of  the  bowel  which  it  occasions,  the  more  prominent  being,  at 
first,  costiveness,  or  difficulty  in  evacuating  the  lower  bowel,  the 
faBces  escaping  in  narrow,  tape-like  coils,  when  the  stricture  is  near 
the  anus;  and  later,  costiveness  alternating  with  diarrhoea,  due  to 
the  inflamed  and  altered  mucous  membrane  above  the  stricture, 
which  now  yields  mucus  mingled  with  pus  and  blood. '^  The  exist- 
ence of  stricture  is  definitely  made  out,  by  the  finger  within  the  rec- 
tum, when  within  its  reach;  the  canal  feels  narrow,  indurated,  and 
unyielding,  though  in  some  instances  the  finger  may  pass  through  the 
obstructed  portion;  if  the  stricture  is  higher  up,  it  may  be  brought 
within  reach  of  the  finger  by  the  bearing  down  effort  of  the  patient;* 
or,  the  patient  standing  erect  and  forcing  down,  may  render  the  ex- 
amination with  the  finger  conclusive.^  Stricture  at  higher  points  is 
diagnosed  with  difficulty,  as  there  is  no  positive  evidence  of  its  exist- 
ence but  that  obtained  by  the  touch; ^  reliance  must  be  placed  upon 

1  T.  J.  Ashton.  2  \v.  H.  Van  Bureu.  3  H.  Smith.  «  G.  Bushe. 

5  J.  P.  Batchelder.  6  R.  Quain. 


THE  RECTUM.  411 

symptoms,  explorations  with  tlie  olive  or  rubber  bougies,  aided  by 
inspection  by  means  of  the  speculum,^  wht^n  the  patient  is  in  the 
prone  position,  on  the  knees  and  elbows. 

The  treatment  is  dilatation,  which  is  best  effected  with  bou'^ies; 
they  meet  two  indications,  namely,  mechanical  stretching  of  the  con- 
tracted tissues,  and  stimulation  of  absorption  of  the  recently  organ- 
ized material  which  constitutes  the  substance  of  the  stricture  ;  the 
bougies  should  be  smooth,  conical  at  the  extremity,  and  of  half  a 
dozen  different  sizes,  varying  from  that  of  the  largest  urethral  bougie 
to  the  diameter  of  an  inch  and  a  half.'^  The  gtun  elastic  and  metal- 
lie  instruments  in  common  use  do  not  compare  in  efliciency  and  pli- 
ability with  the  soft  rubber  ^  dilators  (Fig.  371),  and  should  never  be 
used  when  the  stricture  is  beyond  the  reach  of  the  finger.  Select  a 
dilator  of  sufHcient  length  to  extend  beyond  the  stricture,  and  of  a 
size  to  pass  through  it  without  force;  previous  to  its  introduction, 
empty  the  bladder,  and  wash  out  the  rectum  with  warm  water; 
warm  and  oil  the  bougie,  to  render  it  pliable ;  place  the  patient  on 
the  left  side,  or  recjuire  him  to  lean  over  a  chair,  or  kneel  on  his  bed; 
the  buttocks  being  separated,  introduce  the  bougie  upwards  and  a 
little  backwards  with  the  convexity  towards  the  sacrum,  avoiding  all 
force;  when  suddenly  checked,  withdraw  the  instrument  somewhat, 
and  give  it  a  different  direction;  if  the  stricture  is  more  than  five  or 
six  inches  from  the  anus,  turn  the  point  of  the  instrument  a  little 
forwards  and  to  the  left  side,  to  avoid  the  sacrum  and  enter  the  sig- 
moid flexure.*  The  bougie  should  not  be  left  in  the  rectum,  in  con- 
tact with  the  altered  parts,  more  than  fifteen  or  twenty  minutes,  and 
it  is  sullicient  in  most  cases  to  introduce  it  every  second  day.  To  aid 
the  process  of  dilatation,  the  knife  may  be  employe<l  in  making  very 
limited  incisions,  or  nickiiit;  the  most  resisting  points  of  the  stricture, 
especially  when  it  is  diaphragmatic,  linear,  or  bridle  like,-  or  of  trau- 
matic origin  with  a  dense  cicatrix,  and  situated  at  the  verge  or  within 
a  short  distance  of  the  anus.  Operate  thus;  cany  a  straight,  nar- 
row-bladed  bistoury  on  the  left  forefinger  within  the  stricture  and 
notch  it  at  several  points;  introduce  a  bougie  for  a  minute  or  two, 
and  on  its  withdrawal  pass  a  suppository  into  the  rectum.  ^ 

Linear  rectotomy*»  is  recommended  for  the  cure  of  stricture  which  is  greatly 
indurated,  with  softening  of  (he  mucous  membrane  by  growths,  ulcerations,  and 
fistulous  passages;  it  is  a(l;i|ile(l  only  to  strictures  within  three  and  a  iialf  or 
four  inches  of  the  anus,  or  wiiere  tlie  peritoneiun  is  not  liable  to  be  itnplicated; 
the  patient  lying  on  tlie  back,  and  being  under  the  ainvsthetic,  with  the  index 
finger  of  the  left  hand  as  a'  guide,  pass  a  straiglit  l)istoury  to  the  upper  limit  of 
the  stricture  in  the  posterior  median  line;  now  incise  the  bowel  slowly  until  the 
entire  thickness  is  divided  tlirougliout  the  whole  extent,  including  the  anus. 

1  J.  M.  Sims.         2  w.  II.  Van  IJuren.  3  p.  s.  Wales.  *  G.  Bushe. 

6  H.  Smith.         o  L.  Verneuil. 


412  OPERATIVE  SURGERY. 

The  after-treatment  requires  the  occasional  passage  of  a  rectal  bougie,  during 
the  period  of  repair,  to  prevent  recontraction. 

Other  methods,  liaving  limited  approval,  are,  forcible  dilatation  to  the  extent 
of  laceration  of  the  stricture,  great  caution  being  observed  in  view  of  the  possi- 
bilitv  of  fiecal  extravasation  and  pelvic  cellulitis  and  abscess. i  Such  dilatation 
may  be  effected  with  dilators,  of  which  there  is  a  variety,  but  all  are  constructed 
on  the  same  principle.  Or  the  dilatation  may  be  effected  with  a  membrane 
which  is  applied  to  the  stem  of  the  instrument,  through  which  there  is  a  canal 
into  which  water  can  be  forced;-  the  soft  rubber  dilators 3  have  a  hood  which 
may  be  dilated  in  a  similar  manner  and  are  preferable. 

It  must  be  constantly  borne  in  mind,  in  the  after-treatment,  that 
simple  stricture  is  never  so  cured  as  to  require  no  furtlier  treatment 
after  complete  dilatation  is  effected ;  there  is  a  constant  tendency 
to  contraction  which  must  be  resisted  for  years  by  the  occasional  in- 
troduction of  the  bougie  by  the  patient.*  (2.)  Venereal  or  syphi- 
litic stricture  results  from  the  healing  of  chancroidal  ulcers  of  the 
rectum,  the  walls  having  become  inoculated  by  the  secretions  from 
external  sores,  or  impure  connection,  or  from  inflammation  extending 
from  chancroids  about  the  anus  to  the  areolar  tissue  of  the  rectum, 
followed  by  organization  of  its  products,  or  ulceration  of  the  mucous 
membrane. 

It  occurs  almost  exclusively  in  females,  its  most  frequent  site  being  between 
one  and  two  inches  from  the  anus;  its  symptoms  do  not  materially  differ  from 
simple  stricture,  but  the  presence  of  chancroidal  cicatrices  on  the  genitals  con- 
firms the  diagnosis;  the  treatment  is  b}' dilatation,  antisyphilitic  remedies  being 
valueless. 5  In  old  strictures  which  resist  all  treatment  and  become  sources  of 
permanent  ill  health,  lumbar  colotomy  may  with  propriety  be  performed. ^ 

9.  Prolapse  of  the  rectum  is  the  protrusion  from  the  anus  of 
the  coats  of  the  rectum;  the  length  varies  from  one  to  six  inches, 
or  even  more,  and  the  shape  and  appearance  depends  upon  its  size, 
and  the  condition  of  the  external  sphincter  ;  it  may  form  a  rounded 
swelling  which  overlaps  the  anus,  or  have  (he  form  of  an  elongated 
pyriform  tumor,  the  free  extremity  being  tilted  forwards  or  to  one 
side  ;  if  the  sphincter  is  relaxed,  the  surface  will  have  the  normal 
color  of  mucous  membrane,  but  if  contracted,  the  color  may  be  violet 
or  livid;  the  exposed  mucous  membrane  is  often  thickened  and  gran- 
ular, and  sometimes  ulcerated,  and  the  connective  tissue  infiltrated.'' 
It  is  most  frequent  in  children,  owing  to  less  curvature  of  the  sacrum, 
the  cartilaginous  state  of  the  coccyx,  the  straighter  direction  of  the 
rectum.8  The  causes  are  (1)  constitutional,  as  general  debility,  and 
(2)  local,  as  diarrhoea,  or  constipation,  polypi,  stone  in  the  bladder, 
stricture  of  the  urethra.^ 

The  treatment  must  first  be  directed   to  the  leplacement  of  the 

1  W.  H.  Van  Buren.         2  j.  Arnott;  W.  R.  Whitehead.         3  p.  s.  Wales. 
4  G.  Bushe;    T.  J.  Ashton;  H.  Smith.  5  L.  Gosselin;  E.  Mason. 

6  W.  Allmgham.         ''  T.  B.  Curling.        8  T.  J.  Ashton.        9  H.  Smith. 


THE  RECTUM.  413 

bowel.  Place  the  patient  on  his  side,  or  on  his  knees  and  elbows  ; 
the  buttocks  being  separated,  grasp  the  tumor  in  a  piece  of  oiled 
linen,  make  firm  coinprestiion,  and,  having  reduced  its  volume, 
push  it  within  the  sphincter;  if  there  is  much  congestion,  apply 
cold,  or  if  inflammation  is  present  and  jjrevents  reduction,  resort  to 
leeches,  followed  by  hot  fomentations  of  the  decoction  of  poppy 
heads;  should  contraction  of  the  sjihincter  interfere,  give  an  anajs- 
thetic,  and  if  relaxation  is  not  snllicient,  divide  the  sphincter  by  car- 
rying the  knife  on  the  finger  nail  introduced  within  tlic  Ijowul;  when 
the  bowel  is  returned,  apply  a  pad  of  lint  and  retain  with  the  T-ban- 
dage.^  The  next  step  is  the  removal  of  the  cause,  which,  in  chil- 
dren, may  generally  be  effected,  rendering  any  but  the  simplest  local 
measures  necessary  for  a  permanent  cure.^  In  the  adult,  if  of  long 
standing,  prolapse  of  the  rectum  will  rarely  admit  of  being  remedied, 
except  by  an  operation,^  which  shall  result  in  such  a  degree  of  the 
adhesive  process  as  shall  prevent  the  descent  of  the  bowel.*  The 
object  to  be  obtained  is  to  reduce  the  redundancy  or  relaxation  of 
the  mucous  meml)r  ine,  promote  adhesion  between  the  several  tissues, 
and  brace  up  the  anus  and  sphincter.*  In  the  treatment  of  simple 
prolapsus,  where  there  art;  one  or  more  large  folds  of  mucous  mem- 
brane, and  the  tissue  is  extremely  vascular,  presenting  the  ai)pear- 
ance  of  smooth  velvet,  or  is  superficially  ulcerated  and  readily  bleeds, 
apply  the  strong  nitric  acid  ^  carefully  to  the  whole  or  greater  part 
of  the  diseased  membrane  with  the  same  precautions  as  to  ha^mor- 
rhoids;  if  the  surface  is  extensive,  make  the  application  to  a  part 
only,  and  repeat.*  In  more  severe  forms  apply  a  clamp  to  the  mu- 
cous membrane  and  destroy  the  includeil  portion  with  the  actual  or 
galvanic  cautery.''  Rest  should  be  maintained,  opium  given  to  re- 
lieve pain,  and  hjumorrhage  should  be  suppressed  by  cold. 

Other  metliods  are  as  follows:  With  tootlied  forceps,  pinch  up  one,  two,  or 
more  folds  of  mucous  membrane,  on  opposite  sides  of  the  bowel,  and  include 
them  in  a  firm  ligature;  ^  when  the  prolapsus  is  very  larj^e,  and  a  considerable 
portion  of  the  mucous  membrane  has  become  converted  into  tissue,  approaching 
integument,  remove  loose  pendulous  tlaps  of  skin  which  exist  around  the  mar- 
gin of  tile  anus,'^  ami  portions  of  tiie  mucous  membrane,'-'  as  follows:  seize  the 
fold  of  skin  on  each  side  of  the  anus  with  forceps,  and  with  curved  scissors  re- 
move both  the  skin  and  mucous  membrane;  in  very  severe  cases  four  or  six  ap- 
plications of  the  scissors  may  be  necessary.* 

10.  Polypus  of  the  rectum  is  composed  of  a  somewhat  loose, 
fibrous,  or  fibro-cellular  tissue,  covered  by  natural  mucous  mem- 
brane. It  occurs  more  frequently  in  children,  is  generally  single, 
and  pediculated,  and  located  just  above  the  sphincter;  it  may  be 
soft  and  liable  to  bleed,  or  firm  and  resisting;  the  symptoms  at  first 

1  T.  J.  Ashton.     2  T.  Holmes.     8  R.  Quain.      *  II.  Smith.     5  B.  C.  Brodie. 
6  T.  Bryaut.      "  T.  Copeland-      *  \V.  Hey.      '■•  Dupuytreu. 


414  OPERATIVE  SURGERY. 

are  slight,  but  later  there  is  pa>sage  of  blood,  tenesmus,  the  escape 
of  the  tmuor  which  may  be  mistaken  for  prolapsed  bowel  or  hemor- 
rhoids; examination  of  the  escaped  tumor,  its  reduction,  followed  liy 
exploration  of  the  rectum  with  the  finger,  determine  its  nature;  if 
beyond  the  reach  of  the  finger,  the  presence  of  the  polypus  may  be 
suspected  if  the  faacal  matter  is  groovi  d.  The  treatment  is  removal.^ 
Sometimes  the  pedicle  is  so  frail  that  the  tumor  is  detached  in  the 
examination.^  Bring  down  the  tumor  by  an  enema;  seize  it  with 
forceps  and  apply  a  ligature  to  the  pedicle;  if  the  tumor  slip  under 
the  finger  in  the  effort  to  bring  it  down,  pass  polypus  forceps  over  the 
finger,  seize  the  tumor,  and  twist  it  off  its  pedicle;  arrest  haemor- 
rhage by  cold  or  astringent  injections.^ 

11.  Haemorrhoids,  piles,  result  essentially  from  a  diseased  condi- 
tion of  the  venous  radicals  of  the  rectum,  and  have  been  described 
in  that  connection  (page  227). 

12.  Foreign  bodies  found  in  the  rectum  are  of  two  kinds:  (1)  con- 
cretions, biliary,  intestinal,  and  ftecal;  (2)  substances  swallowed  or 
introduced  through  the  anus,  as  pins,  nails,  fruit-stones,  coins,  small 
bones,  or  pieces  of  wood,  cork,  meat,  bone,  horn,  ivory,  and  metal, 
pots,  cups,  bottles,  ferrules,  rings. ^  The  symptoms  of  the  former  are 
gradual  in  their  accession,  preceded  by  signs  of  derangement  of  the 
stomach,  liver,  and  bowels,  and  weight,  distention,  and  pain  in  the 
rectum,  followed  by  obstinate  constipation,  great  straining,  with  more 
or  less  prolapsus  of  the  mucous  membrane  and  congestion;  exploration 
with  the  finger  reveals  the  nature  of  faecal  accumulations,  and  the 
presence  of  foreign  bodies;  information  as  to  substances  swallowed 
can  seldom  be  obtained,  as  the  patient  is  generally  unconscious  of 
the  fact.  When  the  foreign  substance  has  been  introduced  into  the 
rectum  the  symptoms  are  more  rapid  in  their  development,  and  the 
patient  may  explain  the  nature  and  method  of  introduction  of  the 
foreign  body.*  In  the  removal  of  such  substances  great  care  must 
be  exercised,  that  the  coats  of  the  bowel  be  not  injured.  The  fol- 
lowing instruments  may  be  required:  blunt  hooks,  lever,  gimlet, 
cutting  forceps,  strong  long  scissors  with  probe  points,  a  six-inch 
narrow  saw,  polypus  and  lithotomy  forceps,  speculum,  strong  waxed 
ligatures,  metallic  tubes,  a  probe-pointed  bistoury;  to  all  of  which  a 
crooked  finger  and  small  hand  are  important  adjuncts.^  F£ecal  ac- 
cumulations are  best  broken  up  with  a  lithotomy  scoop,  or  the  handle 
of  a  firm  spoon.  As  a  rule,  extract  the  larger  portion  and  remove 
the  remainder  with  injections.^  The  removal  of  concretions  and 
solid  substances  must  be  effected  with  the  finger,  or  with  forceps. 
Should  the  substance  be  a  bottle,  or  jar  of  glass,  or  earthenware, 

1  H.  Guersant.  2  t.  Holmes.  3  g.  Bushe.  4  T.  J.  Ashto::. 

5  T.  B.  Curliug. 


THE   RECTUM.  415 

insert  slips  of  thin  ivory,  wood,  or  gutta-percha,  between  it  and  the 
bowel,  and  thus  form  a  tube  around  it,  which  will  facilitate  its  ex- 
traction and  protect  the  intestine  from  injury  in  case  the  body  should 
be  broken;  the  anus  being  very  dilatable,  it  will  rarely  be  necessary 
to  divide  the  sphincters,  unless  the  foreign  body  is  sharp  and  angu- 
lar and  has  pcnctralcd  the  intestines.^ 

l.J.  Cancer  of  the  rectum-  is  almost  exclusively  of  the  form  of 
gland  cancer,  as  it  commences  in  the  glands  which  grow  in  the  shape 
of  tortuous  and  branched  tubes;  the  interstitial  connective  tissue  is 
strewn  with  small,  round  cells,  sometimes  softened  and  often  very 
vascular;  tlie  muscular  coat  may  be  at  first  hypertrophicd,  but  sub- 
sequently it  is  also  aifected  by  the  ulceration.  The  first  symj>toms 
are  usually  constipation,  discharge  of  mucus  and  slight  lia;morrliage, 
which  leads  to  the  treatment  for  hicmorrhoids  before  the  diagnosis  is 
made  out;  but  the  induration  and  nodular  infiltration,  leaf-like  pro- 
liferations, connnencing  close  above  the  sphincter  ani,  soon  extend  to 
the  whole  circumference  of  the  mucous  membrane,  so  that  a  thick 
and  prominent  ring,  forming  a  stricture  of  va'^iable  length,  may  be 
felt;  at  later  periods  an  ulcer  is  found  with  elevated  edges  and  in- 
durated base,  and  the  parts  around  are  infiltrated  with  medullary 
substance,  while  ai  some  points  there  is  cicatricial  tissue;  the  in- 
guinal and  retropeiitOMcal  glands  arc  affected  rarely  and  late  in  the 
disease;  death  generally  results  from  the  stricture,  from  marasmus 
due  to  luemorrhages,  and  putrefaction  of  the  cancerous  tissue.  This 
new  formation  can  only  be  removed  by  extirpation. 

14.  Extirpation  of  the  rectum  may  involve  only  a  small  section 
of  the  tube  or  the  entire  bowel,  or  both  the  rectum  and  anus,  accord- 
ing to  the  extent  of  the  disease  ;  complete  extirpation  has  given  the 
most  satisfactory  results. ^  Operate  as  follows  :  the  bowels  having 
been  thoroughly  cleared  by  injection,  place  the  patient,  ana'sthetized, 
on  the  back  and  in  the  position  for  lithotomy,  the  limbs  being  sup- 
ported ;  em[)ty  the  bladder,  and  in  the  male  introduce  a  soimd  as  a 
guide;  if  the  anus  is  involved,  commence  an  incision  at  the  centre  of 
the  perineum  and  carry  it  along  the  raphe  to  the  anus,  encircle  the 
anus,  and  continue  along  the  median  line  to  the  coccyx;  dissect 
along  this  incision  until  the  rectum  is  exposed;  no;v  with  the  fingers 
or  han(ll(!  of  the  scalpel  continue  to  expose  the  bowel  until  a  point  is 
gained  above  the  diseased  mass  ;  draw  the  bowel  down  through  the 
wound,  pass  ligatures  through  the  healthy  portion  ami  carefully  di- 
vide it,  tying  all  bleeding  vessels;  the  stump  of  intestine  is  now  to 
be  attached  to  the  integument  along  the  margin  of  the  wound  by 
sutures  passed  from  within  outwardly.  If  the  anus  is  not  diseased, 
it  may  remain,  the  bowel  being  reached  by  an  incision  from  the  anus 

1  T.  J.  Ashton.  2  T.  Billroth.  a  R.  Volke.ian. 


416  OPERATIVE  SURGERY. 

to  the  coccyx,  but  aarly  and  total  extirpation,  including  the  sphinc- 
ter, is  to  be  regarded  as  the  safer  method.  If  the  peritoneal  cavity 
is  opened  during  the  operation,  use  salicylic  acid^  instead  of  carbolic 
solution,  aj)plied  to  the  peritoneal  wound  with  a  sponge;  but  as  soon 
as  the  ttnnor  is  removed  enlarge  the  external  wound  and  close  the 
peritoneal  wound  with  sutures.  Drainage  tubes  must  be  inserted  so 
as  effectually  to  remove  all  secretions  and  allow  frequent  cleansing  by 
the  injection  of  carbolic  solutions;  tubes  may  be  placed  between  the 
sutures,  and  additional  external  openings  may  be  recpiired  on  either 
side,  through  which  catheters  may  be  carried  to  the  upper  part  of 
the  wound,  for  the  purpose  of  cleansing  with  disinfectant  solutions. 
The  after  treatment  must  be  antiseptic  as  to  the  wound,  and  in  gen- 
eral such  as  to  secure  quiet  of  the  bowels  by  opium;  proper  nutrition 
by  easily-digested  food,  as  milk,  beef  tea,  raw  eggs;  and  perfect 
cleanliness  of  the  wound  externally  and  internally;  the  sutures  must 
be  removed  when  they  become  loose.  The  first  inconvenience  is 
from  incontinence  of  fteces,  but  this  condition  soon  becomes  easily 
tolerated,  and  with  soft  pads  and  bandage  the  patient  is  protected. 

It  is  important  to  provide  for  the  escape  of  gases  after  the  operation.  For 
this  purpose,  an  egg-shaped  air  pessav}'  of  caoutchouc  may  be  emplo3'ed;i  it  con- 
sists of  a  thin,  soft,  India-rubber  bag  with  a  flexible  tube  eight  inches  long, 
ending  in  a  stopcock,  and  traversed  in  its  long  diameter  by  an  ordinary  gum 
catheter  of  full  size;  the  bag  is  air-tight,  and  distensible  at  will  through  the 
tube  stop-cock;  when  used  it  is  introduced  into  the  rectum  after  the  operation 
and  gently  distended  so  as  to  reduce  the  area  of  the  surrounding  extra-rectal 
cavity  to  a  minimum  ;  the  gases  now  escape  freely,  and  the  distention  of  the 
bowel  greatly  diminishes  the  internal  area  of  the  wound. 

The  rectum,  prostate,  and  base  of  the  bladder  have  been  successfully 
removed  for  cancer,'-  as  follows:  A  semilunar  incision  was  made  around  the 
anus  on  both  sides;  tiie  healthy  muscular  fibres  of  the  sphincter  were  pushed 
aside,  and  tiie  finger  passed  up  to  the  extent  of  four  inches,  where  healthy  tissue, 
was  found  surrounding  the  rectum,  except  in  the  anterior  fourth,  where  the 
bladder  and  prostate  were  involved  in  the  cancer;  the  adherent  portion  of  the 
prostate  was  cut  through,  with  the  urethra  contained  in  it;  arteries  were  tied 
and  the  sound  portion  of  the  rectum  drawn  down  and  freed  from  tiie  cancer- 
ous tissues;  the  healthy  intestine  was  then  attached  to  the  skin  by  sutures; 
recovery  was  satisfactory. 


CHAPTER  XXXIX. 

THE  ANUS. 

The  antis,3  the  lower  opening  of  the  alimentary  canal,  is  a  dilat- 
able orifice,  surrounded  internally  by  the  mucous  membrane,  and 
externally  by  the  skin. 

1  W.  H.  Van  Buren.  2  Von  Nussbaum.  8  Quain's  Anat. 


THE  ANUS.  417 

These  membranes  here  become  continuous  and  pass  into  each  other;  the  l()\T'er 
end  of  the  rectum  and  the  niar<;in  of  tiie  anus  are  embraced  by  the  followiuf; 
muscles:  the  internal  spliincter,  the  levators  ani,  the  coccygei,  and  the  external 
sphincter. 

1.  Exploration  of  the  anus  is  mado  as  follows:^  place  the  pa- 
tient in  a  jToud  li^lit,  with  the  body  flexed  and  rostinj^  on  the  ell)ows 
and  the  knees;  by  separating  the  buttocks,  and  <fently  foreinjf  asun- 
der tlie  marLjins  of  the  anal  orifice  with  the  thuiul)s,  a  good  view  of 
the  radial in'4  plaits  and  of  the  festooned  line  of  junction  of  skin  and 
mucous  membrane  may  be  had,  and  possibly  of  the  lower  margin  of 
an  irritable  ulcer;  by  urging  the  patient  gently  and  repeateilly  to 
bear  down,  a  lia-niorrhoidal  tumor  may  be  [)rotruded. 

2.  Contraction  of  the  anus  may  i)e  due  to  a  congenital  nnrrow- 
ing  of  the  lower  part  of  the  rectum  and  the  anus,  or  of  the  anal  ori- 
fice alone,  or  the  integument  may  extend  partially  over  the  anus;  the 
situation  and  form  of  the  anus  are  generally  normal,  but  the  orifice 
is  puckered  or  plicated;  the  narrowing  may  be  slight,  or  only  admit 
the  passage  of  a  probe.  The  symptoms  are  absence  of  meconium, 
and  progressive,  painful  tension  of  the  abdomen,  and  vomiting.  Con- 
traction may  also  result  from  operations,  injuries,  syphilitic  sores. 
The  treatment  is  dilatation  :  Select  a  graduated  bougie,  the  tip  of 
which  readily  passes  the  contraction;  inject  a  little  oil  to  lul)ricate 
the  parts;  or,  if  there  are  faeces  in  the  rectum,  move  the  bowels  first 
with  an  enema;  j)lace  the  patient  on  the  back  with  the  thighs  ■well 
flexed;  warm  and  oil  the  bougie,  and  pass  it  gently  but  firmly  into 
the  constriction;  repeat  the  operation,  daily,  until  the  part  is  en- 
larged to  at  least  its  normal  calibre;  the  finger  may  be  substituted 
for  the  bougie  when  the  stricture  is  suflicicntly  dilated. 

If  the  narrowing  is  extreme,  and  very  rigid  and  unyielding,  incise  the  lateral 
surfaces  on  a  director,  and  in  the  direction  of  the  tuber  ischii,  to  such  a  depth 
as  to  allow  the  passage  of  the  fasces;  if  the  first  incisions  are  not  sufflciently 
deep  repeat  them;  but  it  is  necessarj'  to  divide  only  slightlv  or  partially  the 
sphincter.  If  the  narrowing  is  due  to  extension  of  the  integument,  incise  it  in 
several  places  on  the  director,  and  dilate  daily  with  a  bougie  or  with  the  little 
linger. 

3.  Imperforate  anus  is  generally  caused  by  a  lamina  of  fibro- 
cellular  tissue,  usually  thin  and  transparent,  permitting  the  meco- 
nium to  be  seen  through  it,  and  forming  a  small,  roundish  promin- 
ence, which  is  most  distinct  when  the  child  cries  or  strains;  the 
bulging  membrane  gives  to  the  finger  a  (lou^hy  feel  and  sense  of  ob- 
scure fluctuation;  on  pressure,  it  recedes,  but  reappears  on  removal 
of  the  fing(M';  the  membrane  may  be  very  thick  and  dense,  especially 
at  the  circumference,  when  the  protrusion  will  be  less  prominent.^ 
The  nature  of  the  affection  is  apparent  on  inspection.     If  the  mem- 

1  W.  II.  Van  Bureu.  2  T.  J.  Ashtou. 

27 


418 


OPERATIVE  SURGERY. 


brane  is  thin,  incise  it  at  once;  if  it  is  tliick,  and  there  is  a  doubt  as 
to  the  continuation  of  the  rectum,  delay  a  day  or  two  for  the  rectum 
to  become  distended;  tlien,  while  the  child  is  held  on  its  back,  on 
the  knees  of  an  assistant,  the  thighs  sti-ongly  flexed,  make  a  crucial 
incision  through  the  membrane,  the  point  of  intersection  of  the  in- 
cisions being  the  centre  of  the  anus;  remove  the  intervening  flaps 
with  scissors,  and  dilate  the  opening  daily  with  the  finger  or  a 
bougie.^ 

4.  Absence  of  the  anus  is  characterized  by  the  obliteration  of 
every  trace  of  the  orifice,  the  perineal  raphe  extending  from  the 
scrotum  to  the  point  of  the  coccyx  without  interruption,  and  the 
space  of  the  anus  being  occupied  with  cellulo-fibrous  tissue ;  there 
are  no  external  signs  by  which  the  location,  or  even  existence  of  the 
rectum,  can  certainly  be  ascertained;  if  it  is  present,  and  near  the 
perineum,  fluctuation  may  sometimes  be  detected  by  the  finger  in 
the  perineum,  or  by  pushing  firmly  up  in  the  direction  of  the  rectum, 
while  with  the  left  hand  firm  pressure  is  made  upon  the  anterior 
walls  of  the  abdomen  inward  and  downward  towards  the  finger  in 
the  perineum. 2  If  by  these  manipulations  the  presence  of  the  rectum 
is  detected,  an  operation  will  afford  the  desired  relief.  The  patient 
being  held  by  the  assistant,  as  before  described,  and,  if  necessary, 
the  sound  introduced,  make  an  incision  in  the  median  line  from  a 
point  near  the  scrotuui  to  the  extremity  of  the 
coccyx  (Fig.  386),  through  the  skin  and  super- 
ficial fascia;  repeat  the  incisions,  but  of  grad- 
ually diminishing  length,  carefully  feeling  be- 
fore each  stroke,  to  ascertain  by  fluctuation  the 
presence  of  the  blind  sac  of  the  rectum,  and 
also  the  position  of  the  bladder  or  vagina;  if 
the  rectum  is  not  found  in  the  middle  line, 
search  posteriorly,  as  the  extremity  is  sometimes  displaced  from 
the  centre  ;  the  bowel  will  be  detected  as  a  fluctuating  tumor,  more 
or  less  elastic,  and  of  a  dark  brown 
color  ;  when  recognized,  seize  it  with 
strong-toothed  forceps,  or  pass  a  needle 
armed  with  a  double  ligature  through  it 
and  gently  draw  it  downwards  ;  adhe- 
sions may  be  broken  up  with  the  fingers, 
or  the  knife,  or  scissors;  when  brought 
down  to  a  level  with  the  integument, 
open  the  cul-de-sac  longitudinally,  empty  its  contents,  thoroughly 
cleanse  the  part,  and  unite  the  margin,  by  six  points  of  suture  (Fig. 
387),  to  the  integument  of  the  corresponding  edges  of  the  perineal 
1  T.  J.  Ashton.  2  \y.  Bodenhamer. 


Fig.  386. 


Fig.  387. 


THE  ANUS. 


419 


wound  in  the  exact  sit  nation  of  the  anus;  the  mucous  membrane 
should  overhip  the  external  skin,  to  prevent  the  escape  of  fa-eal  mat- 
ters into  the  cellular  tissue;  close  the  wound  anteriorly  and  poste- 
riorly by  suture;  bind  the  child's  legs  to<xether  with  a  bandage,  and 
apply  cooling  lotions  to  the  wound;  tendency  to  undue  contraction 
must  be  counteracted  by  dilatation. 

If  it  is  found  impossible  to  Xmng  the  bowel  down,  it  must  be  opened  by  a  lon- 
gitudinal incision  at  its  extremity,  and  allowed  to  remain  in  its  position,  the  ex- 
ternal opening  beiiij?  kept  |)atul((iis  by  means  of  curved  silver  canuhe,  in  order 
to  form  that  portion  of  the  rectum  absent. i  Or,  resection  of  the  os  coccygis^ 
ma3'  be  performed,  and  the  rectum  exposed  and  brought  down  and  atiaclied 
to  the  skin. 

5.  Abnormal  anus  is  characterized  by  the  existence  of  fistulous 
openings,  through  which  faecal  matters  are  discharged  at  unusual 
points,  the  normal  anus  being  imperforate ;  the  malformation  is 
recognized  by  the  absence  of  the  anus  and  the  escape  of  fiecal  mat- 
ters from  unusual  outlets,  as  the  vagina  or  urinary  bladder.  The 
treatment  consists  in  establishing  a  more  favorable  outlet,  Avhen  the 
abnormal  anus  is  a  source  of  ill  health.  There  are  several  varieties 
which  may  be  the  subject  of  an  operation. 

0.  The  vaginal  fistula  may  exist  either  with  the  rectum  per- 
fectly formed,  and  continuous  as  a  separate  canal  nearly  to  the  anus, 
where  it  is  occluded  by  tissues  more  or  less  thick,  and  having  a  fis- 
tulous communication  with  the  vagina;  or  the  rectum  may  terminate 
in  a  cul-de-sac  opposite,  or  even  somewhat  above,  the  vaginal  o[)en- 
ing;  the  opening  into  the  vagina  varies  in  size  and  situation,  being 
generally  but  a  short  distance  up  the  canal,  but  sometimes  even  near 
the  OS  uteri  ;  if  the  opening  is  of  small  size,  an  operation  within  the 
first  month  or  two  is  desirable;  the  operation  is  designed  (1)  to  secure 
and  maintain  an  opening  into  the  bowel 
at  the  natural  site  of  the  anus;  and  (2)  to 
close  the  unnatural  opening  into  the  va- 
gina. Where  the  rectum  continues  past 
the  vaginal  opening  down  to,  or  nearly  to, 
the  site  of  the  natural  anus,  introduce  a 
curved  probe  into  the  vaginal  ojiening 
and  make  it  protrude  the  skin  of  the  per- 
ineum at  the  proper  place  (Fig.  388) ; 
cut  dowu  upon  the  probe  to  the  intestine; 
now  detach  and  draw  down  the  mucous  membrane  of  the  rectum, 
if  possible,  and  attach  by  sutures  to  the  edges  of  the  incision,  and 
thus  secure  a  new  anus  (Fig.  387).  But  if  the  rectum,  instead  of 
being  continued  down  to  the  perineiun,  ends  in  a  cul-de-sac  more  or 
1  M.  Amussat ;  W.  Bodenhamer.  2  L.  Verneuil. 


Fig.  388. 


420  OPERATIVE  SURGERY. 

less  high  up,  near  the  vaginal  opening,  dissect  upward  until  the  rec- 
tum is  certainly  opened  and  then  if  the  mucous  membrane  cannot  be 
brought  down  and  attached  to  the  skin,  maintain  the  permanency  of 
the  new  opening  by  the  daily  introduction  of  the  finger ;  a  roll  of 
oiled  linen  may  be  introduced,  but  should  be  continued  only  during 
the  first  twenty -four  hours;  the  new  outlet  being  established,  the 
vaginal  fistula  tends  to  close,  should  it  remain  open  it  must  be  sub- 
sequently closed  by  the  methods  employed  for  fistulse  of  different 
origin.^ 

Or,2  introduce  into  the  tistula  a  director,  and  with  a  bistoury  lay  open  the  va- 
gina and  integuments  as  far  back  as  the  part  wliere  the  anus  should  be;  remove 
a  small  portion  of  the  integuments,  if  necessary,  and  dissect  down  to  the  ter- 
mination of  the  gut,  and  open  it  freely;  the  anterior  boundary  of  the  incision 
is  the  fistulous  opening  in  the  vagina,  and  posteriorly  it  would  terminate  where 
the  natural  outlet  ought  to  be  found;  promote  granulations  and  the  cicatrizing 
of  the  original  opening,  and  so  much  of  the  anterior  portion  of  incision  as  ren- 
ders the  vagina  incomplete;  in  the  mean  time  keep  the  remainder  open  until  this 
shall  have  been  effected  ;  the  integuments  around  the  incision  retract  and  thereby 
obviate  the  necessity  of  removing  them ;  the  original  aperture  closes  up  with 
that  part  of  the  incision  connected  with  it;  the  vagina  becomes  complete,  and  a 
route  direct  from  the  rectum  is  established,  having  no  communication  whatever 
with  the  vagina. 

7.  The  vesical  faecal  fistulae  arc  manifested  by  the  thickness 
of  the  urine,  its  greenish  appearance,  its  passing  only  at  the  time 
of  urinating,  and  with  gases;  this  fistula  is  very  difficult  of  relief.^ 
In  some  cases  the  gut  terminates  in  the  bladder,  directly  after  its 
passage  out  of  the  false  pelvis;  again  the  rectum  descends  low  down 
in  the  pelvis,  even  nearly  to  the  skin  of  the  perineum.*  Make  the 
usual  dissection  for  absent  rectum,  and,  if  found,  treat  it  as  described; 
if  the  gut  is  not  found,  open  the  colon  in  the  left  groin,  as  follows:  ^ 
the  patient  placed  on  his  back,  make  an  incision  (Fig.  352)  two  to 
three  inches  in  length  in  the  left  iliac  region,  commencing  on  a  line 
with  the  anterior  superior  spinous  process  of  the  left  ilium  and  carry 
it  in  a  direction  parallel  with  Poupart's  ligament;  cautiously  divide, 
on  a  director,  the  successive  layers  which  constitute  the  abilominal 
parietes  of  this  region;  open  the  peritoneum  and  recognize  the  sig- 
moid flexure  of  the  colon  l>y  the  sacculi  and  transverse  bands;  pass  a 
ligature  through  the  intestine  to  keep  it  in  apposition  with  the  open- 
ing in  the  abdominal  wall ;  make  a  longitudinal  incision  and  give 
exit  to  the  fa?cal  matter;  employ  injecions  to  cleanse  the  bowel  above 
and  below  the  opening;  adhesions  soon  unite  the  intestines  to  the 
peritoneum  and  the  anterior  wound,  when  the  lips  of  the  woimd  in 
the  intestines  should  be  united  by  sutures  to  the  edges  of  the  exter- 

I  J.  H.  Pooley.        ^  j.  r.  Barton.  3  w.  Bodenhamer.  *  T.  Hohiies. 

5  M.  Littre. 


THE  ANCS. 


421 


nal  (Fig.  373)  wound;  the  tendency  to  contraction  must  be  overcome 
by  occasional  use  of  the  dihitators.     (Fig.  371). 

Other  forms  of  fivcal  tistiilip  may  exist  at  many  other  points,  as  in  the  urethra, 
the  hibia  niajora,  in  the  groin,  and  even  under  tlie  ."icapula;  if  not  found,  the 
colon  should  be  opened  as  above;  the  principles 
of  treatment  are  the  same  in  all,  namely,  en- 
deavor to  form  an  artitieial  anus  in  the  proper 
place,  tlie  perineum,  or,  failing,  perform  colotomy 
at  any  point,  even  at  the  cjeciim  (Fig.  389). 

8.  Absence  of  anus  and  rectum  is 
rare,  and  characterizeil  by  tlie  obliteration 
of  these  parts,  and  the  presence  of  a  dense 
fibrous  tissue  in  their  normal  positions  ;  the 
pelvis  is  sometimes  abnormally  contracted;  ^ 
there  is  no  certain  indication  of  the  pre- 
sence or  absence  of  the  rectum ;  -  the  diag- 
nosis can  be  made  definite  only  by  an  ex- 
ploratory operation,  as  with  a  grooved 
needle,  or  by  an  aspirating  needle,  or  by 
careful  dissection.  If  exploration  is  determined  upon,  wait  a  day  or 
more  for  the  rectum  to  become  distended;  then  insert  the  needle  cau- 
tiously in  the  direction  of  the  greatest  curve  of  the  sacrum.  If  in- 
cision is  made,  give  chloroform,  and  require  the  patient  to  be  helil  as 
for  lithotomy ;  make  an  incision  an  inch  in  length  on  the  spot  where 
the  aiuis  ought  to  be;  continue  the  dissection  in  the  direction  the 
rectum  usually  takes,  not  in  a  direct  course  through  the  axis  of  the 
pelvis,  but  backwards  along  the  coccyx,  the  finger  being  used  as  a 
director,  until  its  full  length  is  attained,  or  the  bowel  is  reached;* 
exploration  should  not  be  made  with  a  trocar, ^  but  with  a  small 
grooved  needle. 

9.  Fissure  of  the  anus  appears  as  an  irritable  ulcer,  and  has  its 
origin  in  a  crack  in  the  mucous  membrane,  where  it  is  about  to  as- 
sume the  character  of  skin;  it  is  more  frequent  in  women,  and  in 
persons  of  an  irritaljle  or  sensitive  nervous  system,  and  in  the  earlier 
portion  of  niiildle  life,  but  may  occur  in  infants.*  The  predisposing 
causes  are,  constriction  of  the  anal  orifice  from  spasmodic  action  of 
the  sphincter,  owing  to  intestinal  irritation  produced  by  the  ingesta 
or  acid  secretions,  from  cicatrization  of  wounds,  specific  ulcers,  in- 
juries, or  ha?Miorrhoids ;  the  exciting  causes  are  constipation,  indura- 
tion of  fa?cal  matter,  and  violent  action  of  the  expulsive  muscles 
requisite  for  its  evacuation.^  The  symptoms  at  first  are  experienced 
only  at  stool,  when  at  some  point  there  will  be  a  smarting,  stin'jing, 


1  RokiiansUy. 
6  T.J.  Ashton. 


-  T.  Holmes. 


8  B.  Bell. 


*  W.  H.  Van  Buren. 


422  OPERATIVE  SURGERY. 

or  prickling  sensation;  later,  the  smarting  during  defecation  will  be 
increased,  or  become  burning,  or  lancinating,  followed  by  excruciat- 
ing aching  and  throbbing,  with  violent,  spasmodic  contraction  of  the 
sphincter  muscle,  continuing  from  half  an  hour  to  several  hours;  the 
stools,  when  solid,  will  be  streaked  with  purulent  discharge  and 
slightly  with  blood,  and  when  more  suft,  will  be  figured  and  of  small 
size;  when  the  ditsease  is  fully  es-tablished,  the  pain  will  be  induced 
by  sneezing,  coughing,  micturition,  forced  respiration,  and  sitting; 
defecation  is  dreaded  and  postponed  ;  highly-seasoned  food  and  fer- 
mented liquors  aggravate  the  symptoms ;  the  pain  often  extends  to 
other  parts,  and  the  urinary  organs  become  deranged.^  In  a  small 
proportion  of  cases  the  pain  does  not  begin  until  after  the  lapse  of 
some  time,  ten  minutes  to  two  hours  after  the  act  of  defecation. ^ 
Severe  pain  in  this  disease  is  due  to  the  pinching  and  kneading  in- 
flicted upon  the  sensitive  sore  by  the  successive  and  unremitting  con- 
tractions of  the  fasciculi  of  ultimate  muscular  fibres  upon  which  it  is 
immediately  situated.^  The  examination  is  generally  attended  with 
much  pain,  and  it  is  often  advisable  to  administer  an  anajsthetic;  if 
the  ulcer  cannot  be  exposed  on  separating  the  parts,  the  speculum 
must  be  used,  or  the  finger  may  detect  its  position  and  extent.^  The 
ulcer  is  met  with  at  or  towards  the  back  part  of  the  gut,  and  not  un- 
fre(|uently  opposite  or  directly  below  the  point  of  the  coccyx;  it  may 
vary  from  the  minutest  point  to  the  size  of  the  end  of  the  finger, 
and  may  be  external,  within  view,  or,  as  a  narrow  chap  or  fissure, 
immediately  within  the  grasp  of  the  external  sphincter;  or  still  higher 
up,  as  an  ulceration  of  the  mucous  membrane,  covering  the  internal 
muscle  an  inch  or  more  from  the  extremity  of  the  bowel ;  the  exter- 
nal ulcer  has  usually  a  yellow  or  ash-colored  base,  but  the  internal 
one  is  often  of  a  vivid  red  color,  and  in  some  instances  the  edges  are 
undermined. 2  If  the  patient  refuses  an  operation,  slight  and  recent 
fissures  may  be  cured  by  cleanliness  and  the  application  of  argent, 
nit.,  followed  by  astringents,  as  a  solution  of  zinci  sulph.,  two  grains 
to  an  ounce,  the  bowels  remaining  at  rest.  The  operations  required 
in  those  cases  which  do  not  heal  is  very  simple  and  effectual,  and 
should  not  Ite  long  delayed ;  they  consist  of  incisions  of  the  base  of 
the  ulcer  or  forcible  dilatation,  with  a  view  to  the  temporary  paraly- 
sis of  the  inflamed  muscle.*  The  bowels  having  been  cleared  by 
castor  oil  or  an  injection,  give  an  anaesthetic  when  there  is  great  sen- 
sitiveness ;  without  an  anjesthetic,  introduce  the  index  finger  of  the 
left  hand,  along  which  pass  a  probe-pointed,  straight  bistoury,  flat- 
wise, to  the  upper  extremity  of  the  fissure,  turn  the  edge  to  the  ulcer, 
and  make  an  incision  down  to  healthy  tissue  the  entire  length  of  the 
ulcer;  with  an  anaesthetic  use  the  speculum;  the  incisions  generally 
1  T.  J.  Ashton.        2  R.  Quain.        3  w.  H.  Van  Buren.        ^  T.  B.  Curling. 


THE  ANUS. 


423 


divide  only  the  mucous  menibrano,^  or  the  more  superficial  muscu- 
lar fibres  of  the  sphincter.'^  If  this  incision  fail,  the  sphincter  must  he 
well  divided,^  but  only  laterally,  for  anteriorly  the  wound  nii'^ht  par- 
alyze the  sphincter  vaginie  in  women.*  and  Injure  the  bull)  in  men, 
and  posteriorly  split  and  separate  the  fdjres  of  the  external  sphincter 
only  and  be  dilHcult  to  heal.^  The  after-treatment  consists  in  main- 
taining cleanliness  of  the  wound,  and  the;  use  of  simple  astringent 
applications. 

The  incision  may  be  made  from  witiioiit  inwards  l)v  passing  a  sliarp-pointed, 
narrow- bladt'd  knife  along  the  base  of  the  ulcer  and  cutting  inwards  upon  the 
finger  or  specniinn.6 

Forcible  dilatation  of  the  sphincter  causes  atony  of  the  muscular 
tissue,  and  thus  interrupts  for  a  few  days  that  constant  motion  wluch 
prevents  the  healing  of  the  fissure;  it  ni;\y  be  most  readily  accom- 
plished by  introducing  both  thumbs  (Fig.  <i90)  well  beyond  the  ex- 
ternal sphincter,  back  to  back, 
then  taking  a  jiurchase  from  the 
buttocks,  with  the  outspread  fin- 
gers carry  the  thumbs  forcibly 
apart  until  the  palmar  surfaces 
are  arrested  by  the  ischial  tuber- 
osities ;  this  act  must  be  per- 
formed thoroughly  and  with 
about  all  the  strength  the  sur- 
geon can  exert  ;  some  of  the 
muscular  fibres  are  generally 
torn  across  and  the  membrane 
lining  the  orifice  is  somewhat 
abraded  or  lacerated,  but  no  harm  results.'^  Instruments  have  been 
devised  for  making  forcible  dilatation  but  they  are  not  preferable 
to  the  hands. 

10.  Fistula  in  ano  is  a  sinus  leading  into  the  cavity  of  an  un- 
healed abscess  near  the  rectum,  either  from  the  external  part,  ex- 
ternal fistula  (Fig.  391),  or  from  the  cavitv  of  the  rectum,  internal 


Fig.  390. 


Fig.  391.  Fig.  392.  Fio.  393. 

fistula  (Fig.  392),  or  from  both,  the  sinus  being  continuous  through 

1  R.  Quain.     2  T.  Brvant.    8  B.  Dover.    *  Sir  B.  Brodie.    &  T.  J.  Ashton. 
6  J.  Svnie.        7  w.  H.  Van  Bnren.  " 


424 


OPERATIVE  SURGERY. 


the  abscess  to  the  external  part,  complete  fistula  (Fig.  393).  The 
external  and  internal  openings  differ  according  to  the  duration  of 
the  disease,  being  prominent,  hard,  and  round  in  phthisical  patients, 
and  in  others,  so  small  as  to  escape  notice.  Generally  there  is  but 
one  internal  opening,  and  that  is  within  five  or  six  lines  of  the  mar- 
gin of  the  anus,  but  not  unfrequently  there  are  several  external  open- 
inn-s.i  In  every  case  of  suspected  fistula,  a  careful  examination 
should  be  made  as  follows  :  the  patient  lying  on  a  table  or  bed,  with 
the  thighs  flexed  and  the  buttocks  projecting,  search  for  the  opening, 
if  it  is  not  evident,  by  pressing  the  side  of  the  anus  with  the  finger; 
a  small  quantity  of  pus  will  ooze  from  the  fistula,  when  it  is  pressed 
upon ;  now  introduce  the  forefinger,  well  oiled,  into  the  rectum, 
which  may  detect  the  orifice  of  the  fistula  as  a  small  depression  on  a 
teat-like  elevation;  insert  a  probe,  slightly  curved,  into  the  external 
opening,  and  carry  it  gently  on,  varying  the  position  of  the  point  of 
the  probe  according  to  the  resistance  it  meets,  but  using  no  force 
until  it  emerges  at  the  internal  opening,  or  is  felt  beneath  the  mu- 
cous membrane.^  Fistulae  are  rarely  cured  except  by  incision  ;  but 
if  the  patient  refuse,  other  means  may  be  used,  as  injections  of  the 
sinus  with  a  solution  of  sulph.  zinc,  or  argent,  nit.,  followed  by  pres- 
sure, or  cauterization  of  the  whole  tract  with  argent,  nit.  The 
operation  of  laying  open  the  sinus  into  the  rectum  is  sanctioned  by 
experience  as  the  most  prompt,  certain,  and  safe  in  its  results;  it  is 
adapted  to  all  cases  except  when  the  patient  is  subject  to  progressive 
organic  disease  in  some  vital  organ,  as  tubercular  disease  of  the 
lungs. 2  Clear  the  bowels  with  castor-oil  ;  an  anajsthetic  having 
been  administered,  place  the  patient  on  the  side  or  back,  with  the 
thighs  flexed;  introduce  the  index  finger  of  the  right  or  left  hand 
into  the  rectum,  according  to  the  side  on  which  the  fistula  exists; 
explore  the  sinus  again  with  the  probe,  to  determine  its  peculiarities; 

now  pass  a  probe-pointed 

bistoury  along  the  course 

of  the  fistula  until  it  emer- 
ges through  the  internal 

opening,  where  it  should 

be  received  upon  the  end 

of  the  finger  (Fig.  304) ; 

with  a  sawing  motion  of 

the   bistoury   divide    the 

intervening    tissues,    and 

bring  the  finger  and  knife 
out  together;  if  there   is  difficulty  in  passing  the  bistoury  introduce 
a  director  to  guide  the  bistoury  (Fig.  395),  or,  l)efore  incision  bring 
1  T.  J.  Ashton.  '^  W.  H.  Van  Bureu. 


Fig.  394. 


Fig.  395. 


THE  ANUS. 


425 


the  end  of  the  director  out  of  the  anus  on  the  finger,  and  then  incise 
the  inchidcd  tissues  (FiL^.  39G)  ;  if  tlie  internal  opening  is  nut  read- 
ily found,  puncture  the  bowel  at  a  point  just  ^.RA^  ,^,  ,~^ 
above  the  sphincter;  ^  when  more  than  one  *iX"M>]^'^  M'/^^'^''^ 
ternal  opening  exists,  lay  them  all  open  at  the  ^^-'r^  -#^ >'V> -  ,'7*^ 
time  of  the  operation, 2  but  make  only  a  single  i^uL 
division  of  the  sphincter;*  but  it  may  be  ad-  ^;>^ 
visable  in  persons  of  feeble  nutrition  to  open 
the   external    sinuses   and   secure  their  union  Y\g.  396. 

before  couipleting  the  operation. ^  If  there  is 
haemorrhage,  tie  any  artery  that  can  be  seized  ;  if  bleeding  is  severe, 
apply  graduated  conijiresscs,  or  ice;  then  insert  strips  of  lint  to  the 
incisions  and  press  them  firmly  to  the  bottom  of  each  wound;  main- 
tain them  in  jiosition  by  T-bandage;  repeat  the  dressings  only  for 
cleanline.>;s,  but  always  force  the  lint  to  the  bottom  of  the  wound, 
without,  however,  breaking  down  the  granulations. 

When  the  fistula  is  of  the  blind,  internal  form,  find  the  opening 
into  the  rectum  by  exposing  the  cavity  with  the  speculum  and  mak- 
ing external  pressure,  which  forces  pus  through  the  oj)ening;  now 
curve  a  probe  so  sharply  that  it  can  be  introduced  into  this  opening 
and  carried  down  to  the  bottom  of  the  abscess,  beneath  the  integu- 
ment; cut  upon  the  probe,  and  thus  render  the 
%  sinus  complete  (Fig-  397),  and  treat  it  accord- 
Vt  ingly.2 

'  Otlier  methods  are,  the  ligature  ''^^ 
(Fig.  398),  galvanocautery,  and  \^ 
dcraseur,  which  are  to  be  preferred  ^' 
only  when  the  incision  is  danger-  ui 
ous,  as  in  blt-cder.s,  or  is  refused,  or  ^ 
in  very  deep  and  extensive  sinuses. 
The  ligature  may  be  silk,  or  elastic 
thread,  the  latter  being  now  pre- 
ferred.* If  silk  is  used,  select  twist  the  thickness  of  common  twine,  and  in- 
sert by  means  of  a  very  slender  silver  probe,  and  secure  the  ends  over  a  small 
button  having  two  holes  at  opposite  points,  and  tighten  every  second  or  third 
day  until  they  cut  their  way  out. 5  If  elastic  ligature  is  used,  pass  an  eyed 
probe  through  the  fistula,  and  bring  it  out  at  the  anus;  then  insert  into  the 
ej'e  an  elastic  thread,  the  size  of  a  quill,  and  draw  it  through  the  sinus,  tighten 
it  and  tie  two  or  three  knots.6  The  galvano-caustic  wire  is  very  easily  in- 
serted along  the  groove  of  the  director;  it  should  be  raised  to  a  dull-red  heat.T 
The  (^craseur  is  passed  through  the  sinus  by  means  of  the  probe  with  a  thread 
attached  to  its  eve. 


Fig.  397. 


Fu;.  308. 


1  \V.  n.  Vaulknen.     -  T.  J.  Ashton.     s  T.  Bryant.     *  T.  Holmes;  T.  Brvant. 
6  S.  D.  Gross.     6  V.  Homanin.    '  H.  G.  Piffard. 


426  OPERATIVE  SURGERY. 

CHAPTER   XL. 

THE   LIVER;    THE   SPLEEN. 

The  liver  and  spleen  are  classified  as  accessory  organs  of  diges- 
tion. 

I.    THE    LIVER. 

The  liver  ^  lies  under  the  right  hypochondrium  and  passes  across 
the  middle  line  more  or  less  into  the  left;  the  extent  to  which  it  can 
be  felt  below  the  edges  of  the  ribs  depends  upon  whether  it  is  en- 
larged or  not,  and  upon  the  amount  of  llatus  in  the  stomach  and 
intestines. 

As  a  rule,  in  health,  its  lower  border  projects  about  half  an  inch  below  the 
costal  carlil;i,i;es,  anil  can  be  felt  moving  up  and  down  with  the  action  of  the 
diaphragm,  but  it  requires  an  educated  hand  to  feel  it;  that  part  which  crosses 
the  middle  line  below  the  ensiform  cartilage  is  much  more  accessible  to  the  feel, 
lying  behind  the  linea  alba  nearly  half  way  down  to  the  umbilicus,  and  hence 
this  is  the  best  place  to  determine  whether  the  organ  is  enlarged  or  pushed  down 
lower  than  it  ought  to  be;  the  fundus  of  the  gall-bladder  is  situated  just  below 
the  edge  of  the  liver,  about  the  ninth  costal  cartilage,  outside  the  edge  of  the 
rectus  muscle,  but  cannot  be  felt. 

L  Abscess  of  the  liver,  though  especially  occurring  in  tropical 
countries,  is  not  infrequent  in  higher  latitudes.  This  fact  is  recog- 
nized when  its  alleged  causes  are  considered,  namely,  dysentery, 
ulcers,  or  other  gangrenous  affections  of  the  abdominal  organs; 
phlebitis  in  the  radicles  of  the  vena  porta,  uterine  phlebitis,  also 
phlebitis  in  the  systemic  veins;  operations  such  as  those  for  lijemor- 
rhoids  and  hernia;  fractures  of  the  cranium;  embolism,  worms,  indi- 
gestion, the  scorbutic  cachexia,  alcoholic  poisoning,  and  heat.^ 

There  are  usually  anatomical  lesions  of  other  organs,  which  we  must  take 
into  consideration  in  ordt-r  perfectly  to  understand  the  pathological  anatomy 
of  the  disease  and  attain  a  clear  insight  into  its  nature:  the  most  important  and 
constant  of  these  are  found  in  the  gastro-intestinal  tract,  the  mucous  membrane 
of  which  is  usually  the  seat  of  exudation  processes  and  ulcerations;  in  most 
cases  these  lesions  are  limited  to  the  large  intestines,  and  occnsionally  the  lower 
portion  of  the  ileum  is  also  diseased;  while  in  the  upper  part  of  the  small  intes- 
tines and  in  the  stomach  the  only  morbid  appearances  observed  are  slight  hy- 
peraemia  and  catarrh,  and  even  these  are  by  no  means  frequent  occurrences. ^ 

It  is  often  extremely  obscure  in  its  origin  and  cause,  it  being  im- 
possible to  detect  its  existence  by  the  most  patient  study  of  symp- 
toms and  careful  examination  of  the  liver.^  There  is  a  class  of 
cases  *  in  which  abscess  may  exist  without  any  local  symptoms  or  such 
general  disturbance  of  the  system  as  is  commonly  regarded  as  indi- 

1  L.  Holdeu.  2  J.  c  Davis.  3  Freirichs.  ■*  W.  A.  Hammond. 


THE  LIVER. 


427 


catin<T  its  presence,  but  associated  with  hypochondria  and  other 
evidence  of  cerebral  derangement.  In  tlie  more  ninrke<l  cases  '  the 
abscess  is  sometimes  preceded  by  a  perceptible  falling-ofT  in  the  gen- 
eral health,  indicated  by  emaciation,  dry  cough  and  enil)arrassed 
resjjiration,  loss  of  appetite,  the  complexion  gradually  assuming  a 
muddy,  sallow  hue;  but  it  more  generally  comes  on  in  the  midst  of 
apparent  health;  the  patient  complains  of  a  feeling  of  abdominal 
uneasiness,  more  particularly  in  the  epigastric  and  hepatic  regions, 
with  some  degree  of  fever,  preceded  by  slight  rigor  or  ague;  but  all 
these  may  be  so  slight  as  often  to  attract  little  attention.  Pain^  in 
the  hepatic  region  is  variable,  sometimes  constant,  at  others  internut- 
tcnt,  or  aggravated  by  movements  of  the  patient,  and  by  jjercussion 
and  pressure;  if  the  abscess  is  deep  in  the  gland,  very  little,  if  any, 
pain  will  be  felt;  if  near  the  surface  of  the  organ,  this  pain  is  sharp 
and  lancinating;  it  may  be  felt  under  the  scapula  and  in  the  shoul- 
der, but  oidy  in  those  cases  where  the  abscess  is  superficial  and  near 
the  convex  surface;  soreness  or  pain  is  found  on  jjressure  over  that 
part  of  the  rib  neai'est  to  the  abscess;  fluctuation  is  difficult  to  de- 
tect in  most  cases,  but  when  present  it  is  one  of  the  most  reliable 
signs  of  hepatic  abscess.  The  general  treatment  should  be  quinine, 
acids,  and  such  hygienic  measures  as  will  best  enable  the  patient  to 
withstand  the  suppuration.^  In  the  obscure  cases  the  abscess  itself 
should  be  opened,  by  aspiration,  at  the  earliest  possible  moment,  and 
without  waiting  for  adhesions  to  form  between  the  liver  and  the  ab- 
dominal walls.^ 

It  is  laid  down  as  a  rule  *  that  in  all  cases  of  hypochondria  or  melancholia  the 
region  of  the  liver  should  be  carefully  explored,  and  even  if  no  fluctuation  be 
detected  or  any  other  si^'n  of  abscess  be  discovered,  aspiration  should  be  per- 
formed, as  it  is  a  harmless  operation;  the  value  of  this  treatment  is  illustrated 
in  several  cases  in  which  cere- 
bral disorder,  with  melancho- 
lia, were  prominent  symp- 
toms, but  in  which  other  indi- 
cations of  hepatic  abscess  did 
not  exist  ;  aspiration  was 
practiced  successfully,  pus 
being  found  in  each,  and  re- 
covery rapidly  following. 

An  exploratory  punc- 
ture may  be  safely  made 
in  the  eighth  or  ninth  in- 
tercostal space  a  little 
posterior  to  a  line  drawn  vertically  from  the  middle  of  the  right  ax- 


FiG.  .399. 


1  Sir  R.  Martin. 
*  W.  A.  Ilanunond. 


2  J.  C.  Davis. 


3  W.  A.  Ilanunond;  J.  C.  Davis. 


428  OPERATIVE   SURGERY. 

illn,  1  (Fig.  399).  If  the  trocar  is  used,  proceed  as  follows: ^  The 
presence  of  pus  having  been  established  by  exploratory  puncture  or 
flucfuation,  the  patient  should  be  directed  to  assume  the  horizontal 
posture  near  the  edge  of  the  bed,  or  table,  with  the  body  projecting 
over  the  side  if  practicable.  If  the  patient  be  timid,  an  anesthetic 
should  always  be  used.  The  skin  is  to  be  drawn  aside  over  the  site 
of  the  puncture,  and  the  trocar  thrust  boldly  in  until  the  cavity  of 
the  abscess  is  reached ;  on  the  withdrawal  of  the  trocar  the  pus  will 
sometimes  spurt  out,  at  others,  slowly  trickle  from  the  canula;  the 
drainage-tube  is  now  introduced  into  the  cavity  of  the  abscess 
through  the  canula;  it  is  a  good  plan  to  use  a  coil,  or  long  piece 
of  tubing,  and  to  mark  the  drainage  tube  at  about  eight  inches 
from  the  end  that  is  to  be  employed;  the  tube  being  in  the  abscess, 
the  canula  is  withdrawn,  and  the  tube  cut  off  at  the  point  desig- 
nated ;  this  simple  procedure  of  dividing  the  tube  after  the  canula  is 
withdrawn  will  prevent  the  serious  accident  of  the  slipping  of  the 
drainage  tube  into  the  cavity  of  the  abscess;  the  free  extremity  is 
now  slit  by  a  crucial  incision;  through  the  four  ends  threads  are 
passed,  the  ends  turned  down  and  secured  by  adhesive  strap  to  the 
skin,  while  the  threads  are  each  wound  around  strips  of  plaster  and 
secured  at  a  distance  from  the  puncture;  the  abscess  is  now  to  be 
washed  out  with  warm  water,  and  after  with  a  carbolized  or  iodide 
solution  ;  a  wad  of  carbolized  lint  is  placed  over  the  puncture,  and 
secured  by  a  loose  bandage ;  the  dressing  must  be  renewed  at  least 
twice  a  day,  the  cavity  thoroughly  washed  and  dressed  as  before; 
the  utmost  cleanliness  should  be  observed  in  nil  minor  details. 

In  using  the  aspirating  trocar,  the  proceeding  is  very  much  simpli- 
fied; ^  wash  out  the  cavity  of  the  abscess  Avith  a  carbolized  or  iodized 
solution,  taking  the  [jrecaution  of  having  the  patient  assume  different 
positions  for  a  minute  or  two  at  a  time,  in  order  that  the  fluid  may 
come  in  contact  with  every  part  of  the  cavity;  this  is  important  in 
order  to  get  any  benefit  from  the  use  of  these  solutions ;  the  trocar 
should  be  of  five  or  more  inches  in  length,  and  of  sufficient  diameter 
to  allow  of  the  easy  passage  of  shreds  of  connective  tissue.  The 
patient  should  be  examined  Avith  care  every  day,  and  whenever 
the  symptoms,  such  as  pain,  weight,  or  uneasiness  in  the  hepatic 
region,  or  an  increase  in  the  volume  of  the  liver,  are  noticed,  the 
abscess  must  be  again  aspirated;  if  the  abscess  is  progressing  favor- 
ably toward  a  cure,  the  intervals  will  be  lengthened,  and  the  quan- 
tity of  pus  at  each  operation  lessened ;  the  number  of  times  that 
puncture  will  be  required  is  impossible  to  determine;  an  approxi- 
mate idea  may  l)e  formed  by  the  quantity  and  chai'acter  of  the  pus 
and  the  general  condition  of  the  patient. 

When  an  abscess  forms  and  presents  under  the  margin  of  the  car- 

1  Jiiiiiiiez;  J.  C.  Davis.  ^  J.  C.  Davis. 


THE  LIVER.  429 

tilages,  it  may  be  evacuated  by  aspiration  or  ineision  ;  the  aspirator 
should  be  used  when  there  is  doul)t  as  to  the  union  of  the  liver  to 
the  abdominal  walls,  but  it'  union  has  taken  place  an  incision  shouM 
be  made  along  the  margin  of  the  cartilages  of  the  ril)s,  tin;  centre 
being  over  the  most  prominent  point  of  the  abscess  (Fig.  352).  The 
cavity  should  be  cleansed  with  carbolic  solutions,  and  free  drainage 
should  he  maintained  while  the  cavity  closes. 

2.  Gall  stones  of  large  size  may  accumulate  in  the  gall-bladder, 
or  oi)struct  its  duct,  and  cause  severe  and  sometimes  fatal  results. 
In  a  well-marked  case  the  following  signs  were  present  :  ^  jaundice, 
intense  itching  of  the  skin,  paroxysms  of  severe  pain  in  right  hypo- 
chondriac region:  a  tumor  appeared  which  was  continuous  with  the 
liver  and  filled  the  right  hypochondrium,  extending  five  inches  and 
a  half  below  the  umbilicus,  and  having  a  transverse  diameter  of  four 
inches  and  a  quarter,  measuring  from  the  linea  alba  towards  the  false 
riljs;  it  was  oblong,  rounded,  and  slightly  movable  laterally;  to  the 
touch  it  was  sensitive  and  hard,  or  tense;  fiuctuation  was  indistinct, 
but  perceptible  ;  aspiration  proved  the  contents  fluid.  For  the  relief 
of  this  obstruction,  cholecystotomy,  incision  of  the  gall  bladder,  was 
performed  as  follows  :  ^  The  necessary  antiseptic  precautions,  with 
carbolic  spray  and  carbolic  solutions  for  the  hands,  sponges,  and  in- 
struments were  taken.  An  incision  was  made  (Fig.  352)  three 
inches  long,  parallel  with  the  linea  alba,  over  the  most  pronunent 
part  of  the  tumor,  about  three  inches  to  the  right  of  the  umbilicus; 
it  commenced  one  inch  above  the  umbilicus  and  extended  two  inches 
below  that  point;  when  the  dissection  exposed  the  peritoneum  all 
ha?morrhage  was  carefully  suppressed;  the  peritoneum  was  now  di- 
vided, and  a  trocar  introduced  into  the  presenting  tumor  and  the 
gall-bladder,  and  twenty-four  ounces  of  fluid  removed;  the  gall-bladder 
was  now  hooked  up  with  a  tenaculum  and  pulled  to  the  outer  edge  of 
the  incision,  where  it  was  seized  with  forceps  and  drawn  out  about 
two  inches;  its  wall  was  then  incised  with  scissors  to  the  extent  of 
about  two  inches,  and  its  cavity  cleaned;  the  edges  of  the  cyst  were 
united  to  the  margins  of  the  abdominal  wound  at  its  upper  angle  by 
fine  carbolized  silk  sutures  passed  entirely  through  the  abdominal 
walls,  including  the  peritoneum;  the  lower  portion  of  the  abdominal 
wound  was  then  closed  by  the  same  suture,  and  cotton  wool  with  car- 
bolized  oil  applied. 

Death  occiuTed  on  the  eighth  dav  from  exhaustion  due  to  hwmorrhages  from 
mucous  surfaces,  owing  to  impairment  of  the  blood  by  the  biliary  salts.  The 
autopsy  revealed  complete  union  of  the  gall-bladder  to  the  abdominal  opening, 
without  peritonitis. 

1  J.  M.  Sims. 


430  OPERATIVE  SURGERY. 


II.  THE  SPLEEN. 
The  spleen  lies  on  the  left  side  beneath  the  ninth,  tenth,  and 
eleventh  ribs,  between  two  lines  drawn  vertically  downwards,  one 
from  the  anterior  and  the  other  from  the  posterior  margins  of  the 
axilla;  its  upper  edge  is  on  a  level  with  the  spine  of  the  ninth  doi'sal 
vertebrfB  and  its  lower  with  ihe  spine  of  the  twelfth  ;  its  position 
and  size  can  only  be  recognized  in  health,  and  very  imperfectly,  by 
a  certain  dullness  on  percussion,  but  it  cannot  be  felt  unless  en- 
larged ;  in  proportion  to  its  enlargement,  it  can  be  detected  below 
the  tenth  and  eleventh  ribs.^ 

1.  Rupture  of  the  spleen  generally  terminates  fatally  by  the 
effusion  of  blood  into  the  peritoneal  cavity,  but  recovery  occasionally 
occurs  when  the  lesion  is  limited  and  the  effusion  slight.  Rest  upon 
the  left  side,  and  the  employment  of  cold,  externally  and  internal, 
must  be  relied  on  to  arrest  hajmorrhage  and  prevent  inflammation, 
with  opium  to  secure  relief  from  restlessness. 

2.  Wounds  of  the  spleen,  punctured,  incised,  and  gun-shot,  are 
commonly  complicated  with  severe  injuries  of  other  organs;  they  are 
frequently  recovered  from,  especially  when  there  is  a  large  external 
opening  with  protrusion  of  the  organ.  An  important  feature  of  these 
wounds  is  that  they  are  not  followed  by  a  tendency  to  suppuration. 
Alterations  of  texture  are  limited  to  the  immediate  vicinity  of  the 
solution  of  continuity;  there  is  little  tendency  to  abundant  pus  for- 
mation, unless  foreign  matters  are  confined,  and  the  bulky  exudation 
products  of  inflammation  are  absent.^  After  shot  injuries  of  the 
spleen  the  powerful  muscular  contractions  seem  to  close  the  opening, 
and  if  this  is  not  sufficient,  coagulated  blood  fills  the  rest ;  in  this 
manner  the  primar}^  bleeding  is  soon  arrested,  and  while  the  throm- 
bosis advances  into  the  injured  blood-spaces  of  the  spleen,  a  tissue 
consisting  of  spleen-tissue  and  blood-thrombi  fills  the  shot  channel, 
and  finally  forms  a  deep  retracted  scar.^  The  treatment  depends 
upon  the  nature  and  extent  of  the  wound;  if  slight,  rest  and  cold 
must  be  relied  on  to  control  the  ha?morrhage  ;  if  large,  with  protru- 
sion of  the  spleen-tissue,  the  protruding  portion  must  be  ligated  and 
cutaway;  this  excision  maybe  safely  carried  to  the  extent  of  re- 
moving the  entire  spleen,  if  damaged  by  the  projectile.  The  spleen 
is  withdrawn  through  the  wound  and  a  ligature  applied  to  the  vessels 
at  the  hilum. 

3.  Hypertrophy  of  the  spleen  may  result  from  lukasmia,  cystic 
degeneration,  and  other  causes,  and  often  attains  enormous  dimen- 
sions. The  only  remedial  measure  is  extirpation,  splenotomy.  Al- 
though extirpation  is  very  successful  in  wounds  with  protrusion,  yet, 

1  L.  Holden.  a  Q.  A.  Otis.  s  Klebs. 


THE  ABDOMEN.  431 

when  removed  for  disease,  the  operation  has  proved  very  fatal. 
There  are  two  ineisions  by  which  tlie  spleen  may  be  removed, 
namely  eentral,  or  lateral ;  the  particular  form  selected  must  depend 
upon  the  size  of  the  tumor:  (1)  Make  an  incision  e.\ten<ling  from 
three  inches  above  the  umbilicus  to  within  three  inches  of  the  pubes; 
divide  the  peritoneum  to  tlie  same  extent;  raise  the  omentum  if  it 
covers  the  spleen;  wlnle  the  organ  is  raised  from  its  position,  ligate 
the  vessels  in  several  parts;  separate  the  attachments  of  the  spleen, 
and  remove  it;  the  cavity  must  be  cleansed  and  the  wound  closed.^ 
(2.)  Make  an  incision  commencing  below  the  ribs  at  a  point  corre- 
sponding to  a  line  extending  upwards  from  the  anterior  superior 
spine  of  the  ilium,  and  curving  downwards  and  forwards  in  front  of 
the  crest;  open  the  peritoneum,  break  up  adhesions,  and  turn  the 
tumor  out  of  the  cavity;  isolate  the  pedicle  antl  tie  it  with  a  strong 
■whipcord  in  four  portions;  tie  bleeding  vessels;  return  the  pedicle 
to  the  cavity,  and  close  the  wound,  2  (Fig.  352). ^ 


CHAPTER   XLI. 
THE   ABDOMEN. 

The  abdomen  is  the  largest  cavity  in  the  body,  and  is  lined  by  an 
extensive  and  complicated  serous  membrane,  the  peritoneum;  it  ex- 
tends from  the  diaphragm  above  to  the  levatores  aui  muscles  below; 
the  enclosing  walls  arc  formed  principally  of  muscles  and  tendons, 
strengthened  internally  by  a  layer  of  fil)rous  tissue  lying  between 
the  muscles  and  the  peritoneum,  the  different  parts  of  which  are 
called  the  fascia  transversalis,  the  fascia?  iliaca,  and  the  anterior 
lumbar  fascia.^  The  extent  of  the  cavity,  the  relations  of  the  en- 
closed viscera,  and  the  peculiarities  of  the  peritoneum,  must  be  borne 
in  mind  in  all  operations  upon  the  abdomen. 

I.    THK  WAbLS. 

1.  "Wounds  involving  oidy  the  abdominal  walls  may  be  of  every 
variety  dcscrihcd.  Simple,  superficial,  incised,  and  lacerated  wounds 
are  not  dangerous.  The  treatment  should  be  modified  by  their  lo- 
cality. In  the  epigastric  region  a  wound  is  apt  to  gape  on  account 
of  the  proximity  of  the  ends  of  the  ribs  ;  if  the  muscles  are  cut  or 
torn  on  either  side  transverse  to  the  direction  of  their  fibres,  atten- 
tion should  be  more  especially  directed  to  the  position  of  the  body 
to  rela.x  those  muscles.  Wounds  in  the  iliac  regions  may  prove 
more  formidable  than  they  appear,  owing  to  their  penetration  into 

1  T.  Billroth.  2  T.  Bryant.  «  Quain's  Anatomy. 


432  OPERATIVE  SURGERY. 

the  vicinity  of  large  artei-ies;^  carefully  clear  the  surfaces  of  all 
foreign  substances,  remove  any  lacerated  tissue  which  might  slough, 
arrest  all  haemorrhage,  by  the  ligature  or  torsion,  and  close  the 
wound  with  closely-applied  silver  wire  sutures  taken  at  such  depth 
as  to  firmly  maintain  the  deeper  parts  in  accurate  apposition;  relax 
the  abdominal  muscles  by  position,  and  apply  long,  narrow  adhesive 
straps  across  the  wound;  complete  the  dressings  with  an  evenly  ap- 
plied bandage  around  the  body.  If  the  wound  involve  the  deeper 
tissues,  especially  the  thicker  parts,  or  wherever  the  muscles  overlap 
each  other,  it  will  be  found  (liflicult  to  maintain  perfect  apposition 
of  the  whole  cut,  and  hence  there  is  a  tendency  to  the  accumulation 
of  serous  or  sanguinolent  fluids  between  the  deeper  surfaces,  which 
are  liable  to  induce  foul  suppuration.^  If  there  is  severe  hajmor- 
rhage,  and  the  wound  does  not  admit  of  the  exposure  of  the  bleeding 
vessel,  enlarge  it  until  the  vessel  can  be  seen  and  secured;  hajmor- 
rhage  need  not  be  feared  while  the  wound  is  open  and  a  finger  can 
be  placed  on  the  bleeding  point;  never  close  the  wound  and  trust  to 
external  pressure  without  securing  the  artery;  suppuration  should 
be  prevented  by  proper  disinfection  of  the  wound  with  carbolic  solu- 
tion and  the  firm  approximation,  by  the  quilled  suture,  of  the  deep 
parts.  If  the  wound  penetrate  the  walls  of  the  abdomen,  the  viscera 
are  liable  to  protrude.  In  punctured  and  small  wounds,  a  part  of 
the  intestine,  omentum,  or  both,  may  escape,  and  are  very  apt  to  be 
constricted  at  their  point  of  exit;  in  incised  and  lacerated  wounds, 
larger  portions  of  viscera  may  protrude,  and  without  marked  con- 
striction.^ Tlie  liands  being  disinfected,  make  a  careful  examina- 
tion as  to  the  nature  of  the  protruded  viscera,  and  the  presence  and 
adherence  of  foreign  substances;  if  the  protruded  i)art  is  appar- 
ently omentum  alone,  ascei'tain  that  bowel  is  not  concealed  in  the 
folds,  or  lying  at  the  base  of  the  protrusion  ;  if  it  is  healthy,  being 
neither  congested  nor  lacerated,  it  should  be  reposited  within  the 
cavity,  the  wound  being  sufficiently  enlarged,  if  necessary,  to  admit 
of  its  return;  but  if  the  omentum  is  bruised,  lacerated,  dirty,  in- 
flamed, or  congested,  or  if  the  mass  be  not  considerable,  but  there  is 
much  resistance  to  its  reduction,  without  enlarging  the  wound,  pass 
a  double  thi'ead  through  the  base  of  the  omentum  and  tie  each  half 
separately,  then  cut  off  all  of  the  mass  anterior  to  the  ligature,  and 
return  the  stump,  allowing  the  ligature  to  depend  from  the  wound;  this 
ligature  will  se[)arate  in  nine  to  fifteen  days.^  With  the  exception 
of  the  omentum,  all  other  protruding  viscera  must  be  returned;  in- 
testines must  be  examined,  and  if  there  is  no  evidence  of  rupture  or 
bruises,  must  be  cleansed  from  dirt,  hairs,  or  other  matters,  by  means 
of  tepid,  disinfected  water,  and  at  once  returned  into  the  abdomen; 

1  G.  Pollock. 


THE  ABDOMEX.  433 

great  care  and  much  gentleness  are  requisite  in  ]ian<lling  a  portion  of 
bowel  whin  the  reduction  is  attempted.  Observe  carefully  the  man- 
ner in  which  the  coils  of  the  bowels  lie  with  regard  to  the  wound, 
and  commence  manipulation  with  the  portion  last  descended  and 
nearest  the  margin  of  the  opening,  passing  up  portion  after  portion. 
If  reduction  is  difficult,  owing  to  the  distention  of  the  bowel  by  gases, 
press  the  air  back,  or,  failing,  puncture  with  an  exploring  needle,  or 
lietter,  with  an  aspirating  needle  attached  to  a  i)ump  or  bulbous 
syringe,^  and  draw  off  the  gases;  if  the  difficulty  ari<e  from  the 
f^mallness  of  the  wound,  enlarge  it  to  tl)e  proper  size  without  open- 
ing the  i)eritoneum  further,  in  the  diiection  of  the  muscular  fibres, 
and  away  from  the  course  of  the  epigastric  or  other  artery.  If  the 
bowel  has  long  been  strangulated,  but  is  not  gangi-enous,  return  it  at 
once;  but  if  it  is  in  a  condition  of  gangrene  establish  an  artificial 
anus."'^  It  is  desirable  to  close  the  wound  at  once;  the  parts  around 
the  wound  must  be  relaxed  by  position ;  to  secure  uniform  apposition 
of  the  edges,  and  maintain  perfect  support,  silver  wire  sutures  are 
to  be  preferred,  and  in  their  application  the  peritoneum  should  be 
included;  the  dressings  cannot  be  too  simple  nor  too  light. - 

Punctured  wounds  are  more  complex  and  dangerous,  especially 
when  they  extend  below  the  fascia?  of  the  abdominal  muscles,  for 
suppuration  is  liable  to  spread  rapidly  in  the  deep  cellular  tissue 
and  between  the  layers  of  muscles;  if  the  wound  penetrates  through 
the  muscles,  but  not  the  peritoneum,  it  may  prove  fatal  from  perito- 
nitis immediately  supervening,  or  secondary  to  the  suppurative  stage; 
the  suppurative  action  may  spread  at  intervals,  in  various  direc- 
tions, and  repeated  abscesses  form  in  different  positions  and  cause 
death  by  exhaustion. ^  In  treatment,  first  control  hajmorrhage;  if  it 
is  not  sufficient  to  justify  an  enlargement  of  the  wound  in  order  to 
apply  a  ligature  to  the  bleeding  vessel,  the  outward  flow  should  not 
be  checkeil  by  external  applications;  if  the  ha;morrhage  be  at  all 
ffee,  the  wound  should  l)e  enlarged  sufficiently  to  allow  the  bleeding 
vessel  to  be  secured,  no  dependence  being  placed  on  pressure  to  re- 
strain h.T?morrhage;  with  the  earliest  suspicion  of  suppuration,  open 
the  wonn<l  freely  to  afford  a  ready  escape  to  the  blood,  serum,  or 
pus  collected  within.'^ 

2.  Abscess  from  injury  may  form  in  the  connective  tissue  beneath 
the  skin,  or  among  the  layers  of  the  different  muscles,  or  between  the 
muscles  and  the  peritoneum  ;3  it  may  be  due  to  perforation  of  the 
bowel,  especially  when  it  conmiences  in  the  cellular  tissue  of  the  loin  or 
iliac  region,  where  it  may  be  slow  or  rapid  in  formation,  and  must  be 
distinguished  from  psoas  abscess,  tumors,  hip-joint  disease.'^  Deep 
abscess  approaches  the  surface  very  slowly,  owing  to  the  interposed 

1  Davidson's.  2  G.  PoUock.  3  S.  D.  Gross. 

28 


434  OPERATIVE  SURGERY. 

structures;  the  symptoms  are  rigors,  severe  pain,  throbbing,  an  in- 
durated swelling,  with  oedema  of  the  cellular  tissue,  iii(]istinct  fluctua- 
tion until  the  pus  is  near  the  surface.  The  early  treatment  should  be 
preventive;  if  pus  is  suspected,  use  hypodermic  syringe  to  explore, 
and,  if  present,  evacuate  it  by  careful  exploratory  incision  ;  if  tlie 
abscess  is  very  deep  the  pus  will  have  a  faecal  odor,  though  the 
bowels  may  not  be  injured. ^ 

3.  Tumors,  fatty,  fibrous,  cystic,  may  form  in  the  abdominal  walls. 
In  diagnosis,  consider  the  history  of  each  ;  examine  the  growth  while 
the  patient  lies  on  the  back,  with  thighs  flexed  and  shoulders  raised^- 
if  in  the  abdominal  walls,  it  may  be  raised  and  the  fingers  passed 
under  it;  if  the  patient  turns,  tlie  tumor  remains  fixed;  but  if  intra- 
peritoneal, it  will  float  about  loosely.  In  extirpation,  make  the  in- 
cisions, as  far  as  possible,  in  the  direction  of  the  muscular  fibres;  use 
the  grooved  director  freely;  tie  all  bleeding  vessels  as  soon  as  di- 
vided ;  in  closing  the  wound,  unite  carefully  the  muscular  and  then 
the  tegumentary  edges,  so  as  to  avoid  the  tendency  to  hernia;  pro- 
tect the  wound  by  long  and  broad  adhesive  strips,  a  compress,  and 
bandage.^ 

II.     THE    UMBILICUS. 

1.  Haemorrhage  is  liable  to  occur  in  the  new  born,  on  the  sepa- 
ration of  the  cord.  If  slight,  it  will  be  readily  controlled  by  astrin- 
o-ents,  as  by  ferri  persidph.  or  styptic  cotton;  if  the  flow  continues, 
apply  the  nitrate  of  silver  in  stick.  If  these  means  fail,  there  is 
some  congenital  defect  in  the  circulation  of  the  liver  which  will  prob- 
ably prove  fatal.  The  lismorrhage  in  this  case  is  to  be  controlled 
by  passing  a  needle  under  the  mass  and  surrounding  it  with  a  liga- 
ture. 

2.  Morbid  groTvths  may  appear  at  the  umbilicus,  namely,  fibrous 
tumors,  wart-like  bodies,  and  cancer;  they  should  not  be  disturbed, 
unless  they  grow,  when  excision  may  be  necessary.  The  cancerous 
tumor  must  be  removed  as  follows  :  make  two  elliptical  incisions  in 
a  line  with  the  long  axis  of  the  body,  which  shall  include  the  entire 
mass  of  disease  ;  dissect  carefully  down  to  the  linea  alba,  in  healthy 
tissues,  penetrate  the  linea  alba,  and  cut  around  the  tumor  on  a  di- 
rector; if  the  abdominal  cavity  is  opened,  carefully  protect  the  in- 
testines; close  the  wound  with  twisted  suture  with  care  passing  the 
pins  outside  of  the  peritoneum;  close  the  lips  of  the  wound  with  fine 
interrupted  sutures  ;  secure  the  parts  with  adhesive  plaster,  com- 
press, and  bandage.'^  The  antiseptic  spray  is  very  necessary,  and 
antiseptic  dressings  should  be  applied. 

1  S.  D.  Gross.  -  "VV.  Parker. 


THE  ABDOMEN. 


435 


III.    THE  CAVITY. 

1.  Ascites,  dropsy  of  the  abdominal  cavity,  may  result  from  many 
causes,  as  disease  of  the  peritoneum,  liver,  iieai-t ;  when  the  accumu- 
lation is  so  great  as  to  cause  inconvenience,  the  fluid  may  be  safely 
evacuated  by  tapping  the  cavity.  The  best  instruments  for  the  op- 
eration consist  of  a  trocar  and  canula,  and  a  catheter  closed  at  the 
end    but   perforated   on   the   sides  by  numerous  holes   (Fig.  400).i 


Fig.  400. 

The  trocar,  in  the  caniila,  is  thrust  into  the  cavity,  and  then  with- 
drawn, leaving  the  canula  in  position;  the  trocar  being  withdrawn, 
the  perforated  catheter  is  introduced ;  the  fluid  now  flows  without 
the  possibility  of  obstruction  by  the  prolapse  of  the  omentum  over 
the  end  of  the  tube,  as  always  occurs  with  the  old  canula.  Place 
the  patient  in  a  sitting  position,  or  upon  the  side  at  the  edge  of  the 
table  ;  surround  the  body  with  a  bandage  sufficiently  wide  to  cover 
the  abdomen;  tear  the  ends  and  make  them  overlap  behind;  take 
the  trocar  or  needle  in  the  right  hand,  the  index  finger  being  applied 


Fig.  401. 

to  the  shaft  within  an  inch  of  the  point;   select  a  place  two  or  three 

inches  above  the  pubes,  in  the  linea  alba,  and  make  an  incision 

1  J.  A.  Wood. 


436 


OPERATIVE  SURGERY. 


through  the  skin  with  the  point  of  the  scalpel;  through  this  incision, 
introduce  the  trocar,  with  a  slight  boring  motion,  until  the  extremity 
is  free  in  the  cavity;  grasp  the  canula  with  the  left  hand,  and  hold 
it  firmly  while  the  trocar  is  withdrawn;  push  the  canula  farther  into 
the  cavity,  and,  if  there  is  a  perforated  canula,  introduce  it  into  the 
open  canula  ;  while  the  fluid  is  escaping,  assistants  should  gradually 
tighten  the  bandage  behind;  when  the  fluid  is  all  removed,  remove  the 
canula  instantly.  Compress  the  edges  of  the  opening  with  thumb  and 
finger,  and  apply  two  long  adhesive  strips,  crossing  at  the  seat  of 
puncture,  and  pin  the  bandage  in  place.  If  the  fluid  stops  suddenly, 
before  suflicient  is  removed,  and  no  perforated  internal  canula  is  at 
hand,  introduce  a  probe  cautiously  to  dislodge  any  floating  substance 
or  omentum  which  may  occlude  the  end  of  the  canula.  If  the  pa- 
tient faint,  arrest  the  flow  by  placing  the  finger  over  the  opening 
while  stimulants  are  administered  (Fig.  401). 


CHAPTER  XLIL 


THE   HERNIA   OF   THE   ABDOMEN. 

The  protrusion  of  any  portion  of  the  contents  of  the  abdomen 
through  an  opening  in  its  parieties  is  a  hernia,  and  the  varieties  are 
named  from  the  particular  positions  of  their  occurrence;  as,  umbili- 
cal, inguinal,  femoral,  obturator;  the  protruding  part  pushes  before 
it  the  membranous  structures  it  meets  in  its  passage,  and  these  fur- 
nish the  coverino;s  of  the  hernia. ^ 


There  are  five  rings  (Fij 


402),  or  natiirallj'  weak  points  in  the  abrlominal 
walls  through  which  the  contents  of  the  abdomen 
may  escape  (Fig.  40.3),  namely,  the  umbilical,  1; 
the  internal  and  external  inguinal,  2,  3 ;  crural, 
4,  and  the  obturator,  5. 


Fig.  402.  Fig.  40-3. 

1.  The  sac  of  a  hernia  is  the  peritoneum,  or  the  membrane  first 
1  J.  Leidy.  • 


THE  HERNIA  OF  THE  ABDOMEN.  437 

protruded.      This  is  always  a  prolongation  of  the  parietal  peritoneum 
from  the  abdominal  cavity. ^ 

Its  formation  ilepeiuls  upon  two  different  conditions,  namely,  either  the  vag- 
inal process  of  the  i)eritoncum  already  existed  as  a  serous  canal  or  sheath, 
tnakin<;  a  conyenital  hernial  sac,  or  it  is  formed  by  a  slow  and  tjradual  process 
of  relaxation,  and  a  stretching,  yielding,  or  elongation  of  the  parietal  peri- 
toneum, due  to  the  pressure  of  the  viscus  itself,  which  constitutes  the  hernia, 
making  the  acquired  hernial  sac.'' 

The  sac  consists  of  a  body,  or  central  part,  above  which  is  the 
neck,  and  below,  the  fundus. 

At  first,  the  peritoneum  forming  the  neck  and  oritice  is  a  plain  membrane, 
puckered  like  the  mouth  of  a  closed  purse,  supported  by  the  ring  or  canal  which 
the  liernia  has  traversed;  next,  these  different  peritoneal  folds  form  adhesions 
together,  owing  to  the  prolonged  contact  of  their  serous  surfaces;  the  con- 
nective and  adipose  tissues  also  seem  to  be  transformed  into  a  new  covering, 
enclosing  a  large  quantity  of  blood-vessels,  the  whole  forming  the  induration  of 
the  neck  of  the  sac  of  an  old  hernia,  rendering  it  independent  of  the  external 
fibrous  ring;  the  oritice  of  the  sac  tends  constantly  to  contract,  and  even  become 
obliterated  when  the  herniated  organs  cease  to  act  upon  it. 2 

2.1  The  contents  of  a  hernia  consist  of  a  part  only  of  the  ab- 
dominal viscera,  and,  in  general,  of  those  which  are  permitted  by 
their  peritoneal  attachments  to  change  their  relative  situations  with 
the  greatest  freedom,  as  the  small  intestines  and  the  omentum;  ^ 
when  the  protruded  viscera  can  be  returned,  the  hernia  is  reduci- 
ble; when  they  cannot,  it  is  irreducible;  if  the  irreducible  is  tempo- 
rarily obstructed,  it  is  incai'cerated ;  if  permanently  obstructed,  it  is 
stran'.nilated. 

3.  The  symptoms  of  hernia  appear  in  the  following  order: 
(1)  there  is  a  sense  of  weakness  in  the  region  in  which  a  hernia 
commonly  occurs:  (2)  fullness,  especially  if  it  is  inguinal  and  the 
patient  is  erect;  (3)  a  small  tumor  is  felt,  which  is  not  permanent, 
but  disappears  tmder  slight  pressure  or  in  the  recumbent  position 
and  reaj)pears  when  the  pressure  is  removed,  or  in  the  erect  posi- 
tion; (4)  it  becomes  more  prominent  when  the  abdomiiud  muscles 
act,  or  on  coughing ;  or  it  may  appear  suddenly,  as  in  infants,  and 
after  violent  exertion  in  adults;  the  contents  modify  the  signs  thus: 
intes  ines  give  a  soft,  yielding,  elastic  swelling,  resonant  on  percus- 
sion, if  filled  with  '.^as,  and  dull,  if  filled  with  fluid;  omentum  is  hard, 
resisting,  and  lobulated.- 

4.  The  diagnosis  of  reducible  hernia  is  generally  very  readily 
and  correctly  made;  but  when  irnduciljli',  or  strangulateil,  the  most 
experienced  cannot  always  determine  without  the  greatest  care  the 
precise  nature  of  the  complaint.*  The  most  disastrous  consequences 
have  followed  errors  of  diagnosis,  and  too  much  care  cannot  be  taken 

1  J.  Leidv.  2  J.  Birkett.  3  g.  D.  Gross. 


438  OPERATIVE  SURGERY. 

in  distinguishing  hernia  from  other  affections  of  the  region  in  which 
it  appears.  The  diagnosis  of  hernia  having  been  made,  its  manage- 
ment requires  a  greater  combination  of  accurate  anatomical  knowl- 
edge with  skill  than  most  other  surgical  affections.  Conditions 
threatening  the  extinction  of  life  occur  at  times  and  in  situations 
demanding  prompt  resolution  and  decisive  action. ^ 

5.  The  truss  is  the  first  appliance  to  be  resorted  to  in  reducible 
hernia;  it  should  be  applied  immediately  that  the  disposition  to  the 
formation  of  rupture  is  detected,  with  a  view  to  procure  adhesions 
of  the  serous  surfaces;  the  rule  applies  to  both  sexes  and  all  ages, 
the  only  exception  being  a  misplaced  testis;-  the  effect  of  such  pres- 
sure is  to  approximate  the  sides  of  the  mouth  of  the  sac,  prevent  the 
descent  of  the  bowel,  and  lead  to  contraction  and  final  obliteration 
of  the  sac. 

As  the  commencement  of  a  radical  cure  bv  truss  pressure  dates  from  the  last 
time  the  bowel  or  omentum  came  into  the  sac,  it  is  of  the  first  importance  to 
prevent  the  liernia  from  ever  coming  down ;  you  must  not  be  content  with  seeing 
the  patient  stand  when  you  fit  a  truss,  but  must  make  him  sit  on  a  low  seat, 
then  stand,  walk,  jump  from  a  stool,  to  see  if  the  truss  completely  retains  the 
hernia;  about  fifteen  to  twenty  per  cent,  may  be  cured  by  judicious  and  persist- 
ent truss-pressure. 3 

6.  Various  operations  have  been  devised  and  performed  with 
a  view  to  the  radical  cure  of  reducible  hernia.  To  be  effectual  and 
permanent  they  must  obliterate  the  sac,  close  the  ventral  orifice, 
strengthen  those  weak  parts  in  the  walls  of  the  abdomen  through 
which  the  rupture  protrudes,  and  improve  the  tone  of  the  peritoneal 
ligaments  of  the  viscera;  they  are  adapted  only  to  those  cases  in 
which  the  protruded  viscus  has  descended  into  a  patent  vaginal 
process  of  the  peritoneum  ;  all  other  kinds  should  be  rejected  as  un- 
suitable.^ 

These  procedures  have  not  accomplished  the  objects  sought  with  that  degree 
of  certainty  which  belongs  to  legitimate  operations,  and  while  they  hazard  the 
life  of  the  patient,  the  complaint  is  very  liable  to  return,  and  the  only  protection 
against  relapse  is  a  truss. * 

7.  An  irreducible  hernia,  not  strangulated,  should  be  treated 
with  a  view  (1)  to  render  it  reducible;  in  small,  recent  hernia,  di- 
rect the  recumbent  position,  low  diet,  and  antiphlogistic;  measures; 

(2)  to  prevent  its  increase;  apply  a  spring  truss  with  a  hollow  pad; 

(3)  to  relieve  suffering;  regulate  the  diet,  bowels,  and  exercise.^ 

8.  The  strangulated  hernia  must  first  be  examined  with  a  view 
to  determine  its  kind  and  variety;  the  duration;  the  hour  at  which 
vomiting  commenced;  the  variations  in  the  composition  of  the  fluids 
ejected;  the  usual  size  of  the  tumor;  its  bulk  before  vomiting;  the 

1  Sir  A.  Cooper.  2  j.  Birkett.  8  J.  Wood. 

*  W.  Lawrence;  T.  Bryant;  F.  H.  Hamilton.        5  S.  D.  Gross. 


THE  IIERNI.E   OF   THE  ABDOMEN.  439 

chan2;es  diirinji  this  stage;  the  pain,  wlicthcr  local  or  extending  into 
the  abdomen  with  or  without  niani|)nhuioii;  the  comlition  of  its  cov- 
erings; its  j)rol)al)le  contt-nts;  the  treatment  already  pursued.^  The 
first  step  in  the  treatment  is  to  endi-avor  to  displace  the  hernia  from 
its  alinornial  position  and  pass  it  through  the  orifice  of  the  sac  into 
the  peritoneal  cavity-  Proceed  as  follows  :  (1)  Before  vomiting  oc- 
curs, abstain  from  manipulation  of  the  tumor  until  other  remedial 
means  have  been  tried;  place  the  patient  on  the  back,  with  knees 
ilexed  and  pelvis  raised,  and  apply  warm  fomentations  over  the  re- 
gion of  the  mouth  and  neck  of  the  sac,  especially  in  children;  sup- 
port the  tumor,  and  give  a  full  dose  of  opium;  if  the  patient  cannot 
maintain  the  position,  or  it  should  be  injudicious  to  enforce  it,  relax 
the  abdominal  muscles  by  allowing  him  to  lie  on  the  side,  the  tumor 
being  carefully  supported;  if  urgent  symptoms  do  not  arise,  a  few 
hours  may  be  allowed  to  elapse  to  afford  time  for  this  treatment  to 
take  effect.  The  taxis  must  next  be  employed  if  reduction  does  not 
follow  the  use  of  the  preceding  measures;  this  is  a  method  of  m;ini[)- 
ulation  and  must  be  practiced  as  follows:  place  the  patient  in  a  po- 
sition to  relax  all  abdominal  muscles  which  contract  around  the 
mouth  of  the  ^ac,  fixing  as  far  as  possible  the  mouth  and  neck  of  the 
sac  with  the  fingers  of  one  hand,  whilst  the  fundus  of  the  tumor  is 
held  in  the  palm  of  the  other,  the  object  being  to  dilate  the  mouth  of 
the  sac  and  diminish  the  bulk  of  the  protrusion,  the  fact  being  borne 
in  mind  that  irreparable  injury  is  frequently  inflicted  upon  the  her- 
niated bowel  by  violence,  and  that  the  danger  of  mischief  by  the 
use  of  the  taxis  increases  in  proportion  to  the  length  of  time  the 
bowel  has  been  strangulated. 

Other  measures  liave  been  employed  to  assist  in  reduction,  with  occasional 
benclit,  as  purgative  enema,  wiiicli  should  not  be  repeated;  reversing  the  trunk 
by  kt;epiug  the  heiid  nearest  tiie  ground  and  the  pelvis  upwards;  encircling  the 
abdomen  with  a  folded  sheet  and  drawing  the  contents  of  the  pelvic  region  up- 
wards whilst  tlie  patient  is  in  the  recumbent  position;  but  the  uncertain  result 
which  aiten<ls  the  employment  of  these  measures,  the  progressive  disease,  the 
risk  to  life  of  delay,  should  deter  from  the  persisting  in  entertaining  hope  of  re- 
duction by  ta.\is  after  its  faihire  under  the  full  influence  of  anasthetics.^ 

(•J.)  During  the  stage  of  vomiting,  cold  may  be  employed  over  the 
mouth,  neck,  and  body  of  the  sac  to  retard  inflammatory  process, 
reduce  nervous  sensibility,  and  permit  advantageous  manipulation  of 
the  tumor;  but  it  should  be  regarded  only  as  a  very  useful  prophy- 
lactic, as  in  cases  where  there  is  unavoidable  delay  in  liberating  the 
bowel  from  constriction,  and  is  scarcely  admissible  as  a  rule  when 
indications  of  strangulation  have  existed  twenty-four  hours,  on  ac- 
count of  the  delay  which  must  necessarily  occur  at  this  important 
moment.  All  other  modes  of  treatment  have  now  been  abaDdoned  in 
1  J.  Birkett. 


440  OPERATIVE  SURGERY. 

favor  of  anaesthetics  which  exert  an  infiiience  over  the  causes  pre- 
venting reduction  more  speedily,  certaiidy,  witli  less  risk  to  life,  and 
mucli  more  within  control.  In  the  administration  of  the  anaesthetic, 
at  this  stage,  have  a  distinct  understanding  with  the  patient  that  if 
the  taxis  fail  the  operation  shall  be  immediately  performed.  As 
soon  as  the  voluntary  muscular  contraction  ceases,  make  gentle  and 
well-preconcerted  pressure,  and,  if  the  taxis  succeed,  the  tumor  will 
gradually  become  softer  or  less  elastic,  smaller  and  of  different  shape, 
until  it  escapes  from  the  embrace  of  the  mouth  of  the  sac ;  taxis,  if 
not  already  abandoned,  must  ;ilways  be  discontinued  altogether  when 
it  is  certain  from  the  vomited  fluids  that  there  is  regurgitation  of  the 
contents  of  the  duodenum  and  jejunum.^  The  failure  of  the  taxis  ne- 
cessitates the  liberation  of  the  hernia  by  a  cutting  operation,  and  the 
surgeon  should  be  duly  impressed  with  the  indisputable  fact  that  upon 
his  discretion,  firmness,  and  resolution  now  hangs  the  fatal  issue,  for 
each  minute  diminishes  the  chances  of  recovery.^ 

9.  The  operation  for  hernia  involves,  more  or  less,  the  following 
considerations:  (1).  The  careful  recognition  of  the  charactei-istics  of 
the  tissues  covering  the  sac,  as  they  differ  in  the  special  regiomd  va- 
rieties.^ In  recent  hernia  the  cellular  tissue  and  fat  will  differ  little  in 
appearance  from  the  ordinary  condition;  but  in  old  herni£e  the  struc- 
tures between  the  skin  and  sac  are  likely  to  be  much  attenuated  ;  ^ 
successive  layers  may  often  be  raised,  sometimes  to  the  number  of 
fifteen  or  twenty.^  The  sac,  in  many  instances,  cannot  easily  be 
distinguished  from  the  cellular  tissue  over  it;^  and  hence  the  follow- 
ing signs  are  useful :  if  the  hernia  is  intestinal  and  not  adherent,  a 
sense  of  fluctuation  may  generally  be  detected  at  the  inferior  part, 
when  the  tumor  is  grasped;*  the  sac  has  a  bluish  vesicular  appear- 
ance, and  if  a  portion  is  pinched  up  between  the  tliumb  and  forefin- 
ger, the  opposite  surfaces  may  be  rubl)ed  together,  which  cannot  be 
done  with  any  other  tissue;  or  a  needle  may  be  introduced,  and  if 
a  drop  of  serous  fluid  escape  this  will  decide  the  question. ^  (2.)  In 
a  comparatively  small  number  of  cases,  the  hernia  may  safely  be  re- 
duced by  dividing  the  stricture  external  to  the  sac;  and  the  question 
may  be  decided  in  each  individual  case  as  follows:  divide  the  stric- 
ture external  to  the  sac  and  reduce  the  mass,  when  the  symptoms  of 
strangulation  have  existed  but  a  few  hours,  and  are  not  very  severe, 
the  vomiting  is  not  stei'coraceous,  the  patient  not  very  prostrate,  the 
tmnor  is  a  simple  enterocele,  and  has  resisted  forcible  attempts  at 
reduction;  open  the  sac  when  strangulation  has  existed  a  long  time, 
with  inability  to  empty  the  sac,  persistence  of  stercoraceous  voniit- 
inii,  prostration,  and  after  repeated,  protracted,  or  forcible  taxis  has 

1  J.  Biikett.       -^  Sir  W.  Fei-gusson.       ^  p.  jj.  Hamilton.      ^  Sir  A.  Cooper. 
6  S.  D.  Gross. 


THE  HERNIA  OF  THE  ABDOMEN.  441 

been  used,  or  the  hernia  is  an  entero-epiplocele  *  or  an  epiploeele. 

3.  An  examination  of  the  contents  of  the  sac  to  determine  their 
condition  and  management.  In  all  cases  there  will  he  more  or  less 
injection  of  the  vessels  of  the  protruded  viscera;  when  the  constric- 
tion has  heen  slight,  the  color  is  nearly  normal:  hut  when  severe  or 
long-continued,  it  may  be  colored  purple,  or  of  blackish  hue,  with 
here  and  there  a  slight  ecchymosis,  and  still  not  l>e  gangrenous;  if 
there  is  doubt,  empty  the  vessels  by  pressure,  and  notice  whether 
they  again  fill,  or  apply  a  cloth  wrung  out  of  warm  water  ten  or  fif- 
teen minutes,  and  note  the  change  in  appearance,  or  puncture  some 
of  its  vessels  to  obtain  a  flow  of  blood.  Notice  the  softness,  the  sen- 
sibility, and  the  temperature.'^  Examine  the  omentum  present,  and 
return  it,  if  healthy,  but  if  it  is  gangrenous,  or  very  bulky,  cut  it  ofif 
near  the  mouth  of  the  sac,  apply  ligatures  to  vessels,  an<l  when  the 
ha?morrhage  has  ceased  return  it  with  its  cut  surface  applied  to  the 
mouth  of  the  sac  and  the  ligatures  suspended  in  the  wound  ;  if  the 
omentum  adhere  to  the  sac,  the  adhesions  may  be  cut  througli  with 
considerable  freedom,  but  the  vessels  must   be   carefully  secured.^ 

4.  Mortification  of  the  intestine  may  be  apparent  before  the  opera- 
tion by  the  pulse  becoming  full  and  soft,  often  intermittent  with  hic- 
cup, freedom  from  pain,  and  less  frequent  vomiting;  the  tumor  also 
becomes  soft  and  doughy,  the  skin  purple,  the  cellular  tissue  empliy- 
sematous  and  crepitant  on  pressure;  the  mortification  may  not  be 
detected  until  the  operation,  when  the  intestine  will  be  dark  purple, 
■with  spots  of  a  leaden  color  or  greenish  hue,  loss  of  lustre  from  a 
film  of  brown  adhesive  matter.^  The  treatment  in  the  first  case  must 
be  by  poultices  to  hasten  separation,  with  supporting  diet  ;  in  the 
latter  case,  (1)  carefully  divide  the  strictine  without  detaching  the 
adherent  intestine  from  the  sac  further  than  may  be  necessary;  (2) 
make  a  firm  incision  into  the  whole  extent  of  the  mortified  portion  of 
the  gut,  and,  as  far  as  practicable,  evacuate  the  gangrened  intestine 
and  the  canal  above  ;  (3)  if  the  gangrene  is  confine<l  to  a  small  spot, 
and  the  adhesion  is  neither  firm  nor  extensive,  replace  all  of  the  in- 
testine except  this  weak  point,  but  if  the  gangrene  is  extensive  and 
adhesions  firm,  leave  the  intestine  in  the  sac,  keep  the  wound  open, 
and  apply  poultices. ^  The  restoration  of  the  fajces  to  the  natural 
passage  will  de]H-nd  upon  the  loss  which  the  cylinder  of  tlie  intestine 
has  sustained;  if  the  opening  is  small,  restrain  the  escape  of  faeces  or 
food  by  the  application  of  gentle  pressure,  and  permanent  closure 
will  fre{[uenlly  occur;  if  the  opening  is  large  and  shows  no  ten- 
dency to  close,  the  only  feasible  operation  consists  in  the  destruction 
of  the  septum,  eperon,  by  the  enterotome. 

1  J.  liirkett.  2  s.  D.  Gross.  »  Sir  A.  Cooper.  *  G.  Pollock. 


442 


OPERATIVE  SURGERY. 


Fig.  404. 


II.     INGUINAL    HERNIA. 

This  form  of  hernia  consists  in  the  protrusion  of  the  abdominal 
viscera  covered  by  the  peritoneum,  15  (Fig.  404),  in  the  course  of 

the  inguinal  canal,  1,  the 
channel,  by  which  the  sper- 
matic cord  passes  through 
the  abdominal  muscles  to  the 
testis. 

This  canal  begins  at  the  inter- 
nal abdominal  ring,  midway  be- 
tween the  symphysis  pubis  and 
the  anterior  superior  spine  of  the 
ilium,  and  ends  at  the  external 
ring,  half  the  distance  from  the 
internal  ring  to  the  symphysis, 
is  two  inches  in  length,  and  paral- 
lel with  and  inunediately  above 
the  middle  of  Poupart's  ligament; 
in  front  the  canal  has  the  apon- 
eurosis of  the  external  oblique 
muscle,  in  its  whole  length  and  at 
the  outer  end  the  fleshy  part  of 
the  internal  oblique,  5  ( Fig.  404) ; 
behind  is  the  transversalis  fascia,  6  (Fig.  404),  and  toward  the  inner  end  also 
the  conjoined  tendon,  7  (Fig.  404)  of  the  two  deep  abdominal  muscles;  below 
it  is  supported  by  the  broad  surface  of  Poupart's  ligament,  which  separates  it 
from  the  sheath  of  the  large  blood 
vessels  descending  to  the  thigh,  ^^^' 
and  from  the  femoral  canal  at  the  ^  '' 
inner  side  of  those  vessels ;  the  sper- 
matic cord,  composed  of  arteries, 
veins,  nerves,  and  excretory  duct, 
occupies  the  canal,  and  receives 
from  the  abdominal  wall,  as  cover- 
ings, the  cremasteric  muscle  (Fig. 
404),  the  infundibuliforna  fascia,  10 
(Fig.  404),  and  spermatic  fascise,  12 
(Fig.  404);  the  epigastric  artery, 
1-3  (Fig.  404),  arising  from  the  ex- 
ternal iliac,  accompanied  by  two 
veins,  ascends  under  cover  of  the 
transversalis  fascia,  6  (Fig.  404), 
along  the  inner  side  of  the  inter- 
nal ring,  close  to  the  edge  of  the 
aperture,  or  at  a  short  interval  from 
it,  the  vessels  of  the  spermatic  cord  being  near,  while  the  vas  deferens,  in  turn- 
ing from  the  ring  into  the  pelvis,  curves  around  it.i 
1  Quain's  Anatomy. 


Fici.  40.3. 


THE  HERNIA.    OF   THE  ABDOMEN. 


443 


Fig.  406. 


Herniae  in  tliis  region  are  oblique,  1,  or  direct,  2  (Fi^.  405). 
Oblicjue  lierniii  ]>asses  through  the  internal  ring  into  the  inguinal 
canal,  forming  a  huhonoeele,  1  (Fig.  4(»5),  then  emerges  from  the 
external  ring  and  enters  the  scrotum;  the  mouth  of  the  sac  is  situ- 
ated to  the  outer  side  of  the  internal  epigastric  artery,  l;J  (Fii;.  404), 
and  its  neck  and  hoily  are  usually  in  front  of  the  structures  compos- 
ing the  spermatic  cord  (Fig.  40G).  Tlie  di'velopment  of  the  sac  dif- 
fers essentially  in  respect  of  the  age  of  the  individual  ;  namclv,  in 
infancy,  youth,  and  early  manhood,  the  disea>e  is  usually  dependent 
upon  the  persistence  of  a  serous  canal, 
or  sheath,  in  direct  communication  with 
the  peritoneal  cavity,  which  a  portion  of 
bowel  or  omentum  may  enter  and  ftjrm 
a  hernia  at  any  perioil  of  life;  but  in 
adult  life  the  sac  is  a  distinctly  new  for- 
mation, of  slow  development,  ami  with 
progressive  stages.  Direct  hernia,  2 
(Fig.  405),  merely  traverses  that  small 
portion  of  the  inguinal  canal  which  lies 
immediately  behind  the  external  ring;^ 
its  path  through  the  conjoined  tendon  is 
represented  by  the  dotted  line  C)n  either  side  of  7  (Fi'_^  404). 

1.  The  symptoms  and  appearances  of  inguinal  hernia  are 
generally  suHiciently  characteristic,  I)Ut  even  in  the  mosi  marked  case 
it  is  important,  by  a  formal  inquiry  and  the  recognized  tests,  to  dis- 
tinguish it  from  different  affections  which  occur  in  these  organs  and 
tissues. 

The  more  noticeable  are  hydrocele,  encysted  spermatocele,  connected  with 
the  epididymis;  varicocele  of  the  spermatic  veins;  influmination  of  an  old  her- 
nial sac  and  its  results;  hiflammatorv  affections  and  otlier  diseases  of  the  testis, 
cord,  and  llieir  coverings,  of  inguinal  and  jympiiatic  glands;  Inematocele;  mal- 
positions of  the  testis;  growths  of  fat  in  the  connective  tissue  of  the  inguinal 
canal  and  upon  the  spermatic  cord;  diseases  of  the  integuments  of  the  scrotum, 
especially  growths.^ 

2.  The  truss  selected  for 
the  early  treatment  of  this 
hernia  nuist  be  preventive  and 
curative.  It  is  of  great  im- 
portance to  protect  those  who, 
from  hereditary  tendency  or 
weakness  of  the  abdominal  walls,  are  predisposed 
to  rupture. 

For  this  purpose  a  broad  band  with  a  suitable  pad  (Fig.  407)  may  be  worn 
1  J.  Birkett. 


Fig.  407. 


Fig.  408. 


444 


OPERATIVE  SURGERY. 


IFig.  408).  It  should  consist  of  stout  elastic  web,  which  passes  round  the  body, 
and  is  attached  to  the  pad  in  front  by  metallic  loops  engaging  studs  on  the  pad; 
elastic  bands  pass  from  the  body  band,  under  the  limbs,  to  studs  upon  the  rup- 
ture pads. 

If  the  patient  is  corpulent,  two  pads  (Fig.  409)  should  be  used  to  give  more 
extended  support  to  the  abdomen  (Fig.  410). 

If  hernia  exist  and  is  reducible,  a  truss  must  be  selected  accord- 
ing to  tlie  size  of  tlie  aper- 
ture; it  should  not  press  in 
tlie  tissues,  nor  invaginate 
them  into  the  canal  between 
the  pillars  of  the  external 
Fig.  409.  abdominal      ring,    and     thus 

stretch,  fray,  and  weaken  the  intercoiumnar  fas- 
cia. ^  Fig.  410. 

The  bearing  of  ihe  surface  of  the  pad  should  be  flat,  the  edge  rounded  off,  the 
shape  being  an  oblique  oval.  The  best  substance  for  the  pad  is  vulcanite,  and  it 
should  be  maintained  in  position  by  a  side-spring  which  encircles  the  body  mid- 
way between  the  trochanter  and  the  anterior  superior  iliac  spine;  sometimes  it 
is  necessary  to  wear  a  perineal  band  which  buttons  in  front,  but  this  may  be 
dispensed  with  when  the  truss  has  accommodated  itself  to  the  shape  of  the  body.i 
A  great  variety  of  trusses  may  be  found,  but  unless  they  conform  in  construc- 
tion to  the  principles  given  the\- 
will  fail  to  meet  the  indications. 
The  several  instruments  most 
worthv  of  consideration  are 
(Fig.  411):- 

rt,  the  single  truss,  adapted  to 
adults  or  infants;  b  is  the  con- 
vex pad  with  ball  and  socket  at- 
tachment ;  c  is  a  convex  pad 
with  ball  and  socket  attachment,  and  set  screw  for  giving 
any  desired  position  to  the 
pad;  d  is  a  double  truss  with 
broad  pads  for  old  ruptures; 
e  and  /  are  reversible  pad 
single  trusses,  applied  from 
ruptured  side,  the  pads  hav- 
ing a  sliding-arm  attachment 
secured  by  a  set  screw;  (f  is  a  double  truss  of  same 
kind.  The  application  of  the  truss  (Fig.  412)  re- 
quires the  spring  to  be  passed  across  the  body  from 

the  well  side,  and  the  longest  diameter  of  the  adjust-    |(R^\    ^         ^     "**'^'il'l 
able  pad  to  be  placed  in  the  line  of  rupture.  '  ^        p       .^_    " 

To  prevent  undue  pressure  upon  the  cord,  which  may  be  so  great  and  long- 
continued  as  to  cause  atrophy  of  the  testicle,  a  pad  has  been  devised  i  with  a  slit 
or  chink  (Fig.  413),  which  gives  a  horse-shoe  shape,  the  shorter  end  lying  upon 
Poupart's  ligament,  immediately  outside  and  above  the  spine  of  the  pubis,  the 

1  J.  Wood. 


Fig.  411. 


THE  HERXLE   OF   THE  ABDOMEX. 


445 


longer  end  lying  on  the  inner  pillar;  the  inner  border  of  the  pad  being  par&llel 
to  tlie  outer  edj?e  of  tlie  rectus  mus- 
cle, while  the  round  part  presses  upon 
the  internal  ring,  and  the  movable 
cord  slips  into  the  chink  between  the 
two  points  of  the  pad,  and  escapes  all 
injury. 

3.  The  radical  cure  may  be 

(letcriniiR'd  upon  in  some  c-ases, 
and  the  folluwing  method  is 
then  advised  :  -  —  Fig.  413.i 


Fig.  414. 


(Fig.  414. )3  Place  the  patient  on  his  back,  with  the  shoulders  raised,  the 
knees  bent,  the  pubes  shaved,  the  rupture  reduced, 
and  give  an  antesthetic;  make  an  incision  about 
an  inch  long  in  the  skin  of  the  scrotum,  over  the 
fundus  of  the  hernial  sac  ;  carry  a  small  tenotomy 
knife  tiatwise  under  the  margins  of  the  incision, 
so  as  to  separate  the  skin  from  the  deeper  coverings 
of  the  sac  to  the  extent  of  about  an  inch,  all  round; 
pass  the  forefinger  into  the  wound  and  iuvaginate 
into  the  canal  the  detached  fascia  and  fundus  of 
the  sac.  The  finger  now  feels  the  lower  border  of 
the  mternal  oblique  muscle,  which  must  be  lifted 
forwards  to  the  surface;  by  this  means  the  outer 
edge  of  the  conjoined  tendon  is  felt  to  the  inner 
side  of  the  finger.  Carry  a  stout  semicircular 
needle,  mounted  in  a  strong  handle,  with  a  point 
flattened  antero-posteriorly,  and  an  eye  in  its  point, 
carefully  up  to  the  point  of  the  finger  along  its  inner  side,  and  transfix  the 
conjoined  tendon  and  the  inner  pillar  of  the  external  ring,  when  the  point 
is  seen  to  raise  the  skin,  draw  the  latter  towards  the  median  line,  and  make 
the  needle  pierce  it  as  far  outwards  as  possible;  hook  into  the  needle  a  stout 
copper  wire,  silvered,  about  two  feet  long,  draw  it  back  into  the  scrotum, 
and  detach:  next  place  the  finger  behind  the  outer  pillar  of  the  ring;  raise 
that  and  Poupart's  ligament  as  much  as  possible  from  the  deeper  structures; 
pass  the  needle  along  the  outer  side  of  the  finger,  through  Poupart's  liga- 
ment a  little  below  the  internal  ring,  and  through  the  skin  puncture  made 
before;  hook  the  other  end  of  the  wire  to  the  eye,  draw  it  back  into  the  scro- 
tal puncture,  and  detach;  pinch  up  the  sac  in  the  wound  with  the  finger  and 
thumb,  forcing  the  cord  backward,  and  pass  the  needle  across  behind  the  sac, 
entering  and  emerging  at  tl-.e  opposite  ends  of  the  scrotal  incision;  hook  the 
end  of  the  inner  wire  on  the  needle  and  draw  it  back  across  the  sac  and  de- 
tach; now  draw  down  both  ends  of  the  wire  until  the  loop  is  near  the  surface  of 
the  groin  above,  then  twist  ih?m  together  down  into  the  incision,  and  cut  off  to 
a  convenient  length.  Traction  on  the  loop  invaginates  the  sac  and  scrotal  fascia 
well  up  into  the  hernial  canal;  twist  the  loop  of  wire  down  close  into  the  upper 
puncture,  bend  it  down  to  lie  joined  to  the  two  ends  in  a  bow  or  arch,  under 
which  place  a  stout  pad  of  lint,  and  secure  the  whole  by  the  spica  bandage;  re- 
tain the  wire  from  ten  to  fifteen  days,  or  longer,  according  to  the  consolidation  ; 
untwist  and  withdraw  upwards. 

1  G.  Tiemann  &  Co.        ^  j.  Wood;  T.  Bryant;  T.  Holmes.        3  T.  Uryaut. 


446 


OPERATIVE  SURGERY, 


It  has  been  reported  ^  that  a  radical  cure  may  be  easily  effected  by 
exciting  the  inriammation  in  the  tendinous  tissues  about  the  ring,  by 
the  injection  of  a  few  drops  of  a  sohition  of  the  fluid  extract  of  quer- 
cus  alba,  and  morphine,  in  the  proportion  of  ^i.  of  the  former,  to 
gr.  ss.  of  the  latter,  into  those  tissues. 

4.  Strangulated  oblique  inguinal  hernia,  which  has  resisted 
well-directed  taxis,  while  the  patient  is  fully  anaesthetized,  must  be 
at  once  liberated  by  division  of  the  stricture. 

The  coverings  are  (Fig.  404):  (1)  skin,  (2)  superficial  fascia,  (3)  intercokim- 
nar  fascia,  (4)  cremaster  muscle,  (5)  infundibuliform  fascia,  (6)  subserous  cel- 
lular tissue,  (7)  sac. 2  The  anatomical  points  to  be  particularly  sought  are  (1) 
the  external  ring,  (2)  the  aponeurosis  of  the  external  oblique  muscle,  (3)  the 
internal  ring,  (4)  the  mouth  of  the  sac;  and  the  length  of  tlie  incision  should  be 
just  sufficient  to  expose  freely  these  anatomical  parts.3 

This  operation  should  be  performed  with  careful  attention  to  all  of 
the  details  required  in  the  use  of  antiseptic  dressings, 
Provide  an  ordinary  hernia  knife*  (Fig.  415),  a  com- 
mon scalpel,  probe-pointed  bistoury,  forceps,  director, 
carbolized  sponges,  carbolic  water  1  to  20,  and  a  hand 
or  steam  spray  apparatus,  and  carbolized  gauze.  Place 
the  patient  on  a  firm  low  table;  shave  the  parts  and 
wash  them  with  carbolized  water;  give  the  anaesthetic 
fully;  raise  the  shoulders,  and  slightly  flex  the  thigh 
of  the  affected  side.  The  spray  being  steadily  directed 
to  the  region  about  to  be  exposed,  make  an  incision 
through  the  skin  over  the  neck  and  body  of  the  tu- 
mor, its  upper  extremity  being  nearly  midway  between 
the  anterior  superior  spinous  process  of  the  ilium  and 
the  tuberosity  of  the  pubes,  aliout  one  inch  and  a  half 
above  the  level  of  Poupart's  liga- 
ment, and  its  lower  about  the 
middle  of  the  scrotum  (Fig.  41 6). ^ 


'///.' 


Or,  with  the  aid  of  an  assistant,  raise 
a  fold  of  integument,  pass  a  sharp- 
pointed  bistoury  through  its  base,  and 
cut  it  outwards  (Fig.  417). 


Fig.  415.6 


This  incision  exposes  the  intercolumnar 
fascia  which  forms  the  first  and  thickest  cov- 
ering of  the  sac;  divide  this  by  raising  with 
forceps  (Fig.  418)  or  on  a  director,  when  the 
cremaster  muscle  will  be  exposed,  which  must 
Fig.  416.  be  cut  in  a  similar  manner,  and  this  incision 

lays  bare  the  sac  (Fig.  419).    The  division  of  these  layers  often  causes 

ij.  Heaton.  2  H.  Gray.  3  j.  Birkett.  ^  Sir  A.  Cooper. 

6  Sir  W.  Fergusson.  «  G.  Tiemann  &  Co. 


THE  IIERSIJE   OF   THE  ABDOMEN. 


447 


great  embarrassment  and  delay,  for  the  operator,  expecting  to  «ee  tlie 
sac  itself,  when  he  has  divided  the  integuments,  ndstakes  this  thick- 
ened covering  and  the 
cremaster  muscle  for  the 
hernial  sac,  and  cuts  the 
fascia  with  extreme  cau- 
tion, fil)re  bv  fil)re.^  Open 
the  sac  with  exceedingly 
great  care,  to  avoid  in- 
cluding the  walls  of  the 
bowel,  either  seizing  the 
sac  with  forceps  (Fig. 
4 18),  or  raising  it  between 
the  thumb  and  fingers. 
Make  an  opening  suffi- 
ciently large  to  admit  a 
grooved  director  with  the  scalpel,  the  sharp  edge  of  which  is  di- 
ivcted  laterally,  the  side  of  the  blade  being  placed  nearly  Hat  on  the 


Fig.  417. 


Fig.  418. 


ri(..  4!ii. 


tumor;  divide  the  sac  on  the  director,  pressed  firmly  against  its  in- 
side ^  (Fig.  419).  Tf  tiie  intestine  is  connected  with  the  sac  by  adhe- 
sions, an  extraordinary  amount  of  caution  is  required  in  opening  the 
sac,  as  it  contains  little  or  no  fluid;  '  next,  pressing,'  the  finger  upon 
the  sac,  insinuate  it  through  the  external  inguinal  ring,  to  ascertain 
if  there  be  any  structures  which  firmly  encircle  the  neck  an<l  orifice 
of  the  sac  outside;  if  any  are  found,  introduce  a  grooved  director 
underneath,  and  cut  them;  make  slight  pressure  upon  the  sac  to  re- 
turn its  contents  into  the  abdomen;  if  reduction  be  impracticable, 
open  the  sac  sufficiently  to  reach  its  orifice  easily;  pass  the  inde.x 
finger  along  the  anterior  surface  of  the  protrusion  upwards  towards 
the  mouth  of  the  sac,  when  the  stricture  will  be  encountered;  the 
1  Sir  A.  Cooper.  2  J.  Birkett. 


448 


OPERATIVE  SURGERY. 


palm  being  upward,  pass  the  hernia-knife  flatwise  along  the  finger 
(Fig.  420),  or  on  a  grooved  director,  through  the  mouth  of  the  sac; 

turn  the  knife  so  as  to 
cut  parallel  with  the 
linea  alba,  and  divide 
the  structures  in  con- 
tact with  it  sufficiently 
to  allow  the  ungual 
phalanx  to  pass  freely 
into  the  abdominal 
cavity.^  Carefully  ex- 
FiG.  420.  amine    the   protruded 

intestine  to  determine  whether  the  brown  color  which  it  assumes 
under  strangulation  lessens  or  disappears,  the  proof  of  a  return  of 
circulation;  the  intestine  should  also  be  pulled  down  a  little  to  ex- 
andne  the  part  immediately  compressed  by  the  stricture;  the  veins 
on  the  surface  may  be  emptied  by  pressure,  and  their  sudden  fill- 
ing noted;  if  the  intestine  appears  to  have  free  circulation,  relax 
the  parts  by  position,  and  directly  but  gradually  return  it,  replacing 
about  an  inch  at  a  time,  and  securing  each  i)art  with  the  fingers 
until  the  whole  is  returned  into  the  abdomen.  The  contents  of  the 
hernial  sac  should  be  exposed  to  the  carbolized  spray,  and  then  re- 
turned ;  all  violence  and  improper  haste  should  be  guarded  against, 
for  the  intestine  is  tender,  and  will  easily  tear  at  the  strictured 
part.2  Clear  the  parts  of  blood,  and  having  nicely  adjusted  the  sac 
and  its  coverings  introduce  a  drainage  tulie;  now  bring  the  edges 
of  the  wound  together,  and  retain  them  by  sutures;  the  needle  and 
ligatures  should  be  passed  through  the  integuments  only,  great  care 
being  taken  to  avoid  penetrating  the  sac;  apply  a  piece  of  lint,  and 
over  it  a  compress  with  a  T-bandage,  so  as  to  close  the  orifice  of  the 
sac;  while  the  patient  is  being  carried  to  his  bed,  support  the 
wounded  part  with  tlie  palm  of  the  hand.^  Or  antise[)tic  dressings 
may  be  applied  so  as  to  fill  the  groin,  and  be  supported  by  the  gauze 
bandage  applied  around  the  body,  and  as  a  spica  to  the  thigh. ^  The" 
important  feature  of  the  after-treatment  is  the  diet,  which  shoidd  he 
farinaceous,  with  milk;  opium  should  be  used  when  required;  the 
bowels  are  often  relieved  spontaneously,  but  if  they  remain  inactive, 
and  any  discomfort  arises,  give  an  enema  of  warm  water,  or  gruel 
with  common  salt,  or  a  little  castor-oil;  if  thirst  is  distressing,  give 
ice;  stimulants  are  often  required  soon  after  the  operation,  but  should 
be  given  in  small  quantities,  and  the  addition  of  thirty  drops  of 
laudanum  is  frequently  very  useful.^  If,  instead  of  rapid  union,  the 
connective  tissue,  the  wound,  the  omentum,  or  the  hernial  sac  in- 
1  J.  Birkett.  2  Sir  A.  Cooper.  »  J.  Lister. 


THE  EERyijE  OF  THE  ABDOMEN.  449 

flame,  remove  tlie  Inwi-r  suture,  or  all  of  tliem,  to  secure  free  drain- 
age, and  a  lopt  tin-  treatment  for  inflamed,  ?up[)urating,  or  slou"hinc 
wounds.^  Thorough  disinfection  of  the  wouiul  at  all  stages  by  car- 
bolic acid  solutions  is  most  important.  If  the  sac  contain  both 
omentum  ami  intestine,  the  former  will  be  in  front,  and  when  omen- 
tum is  found  search  should  be  matle  to  ascertain  if  there  is  not  a 
small  knuckle  of  intestine  behind.^ 

Omentum  is  much  less  capable  of  resisting  the  effects  of  iuflammaiion  than 
intestine,  ami  is  frequently  not  in  a  condition  to  he  replaced  when  the  latter  is; 
when  intlained,  the  omentum  is  less  discolored  than  the  intestine,  and  loses  it8 
consistence,  and  if  the  tests  applied  to  the  intestine  prove  feeble  circulation,  the 
omentum  should  be  excised:  it  should  also  be  excised  when  much  enlarged  by 
intestinal  deposits,  or  liable  from  its  bulk  to  excite  peritonitis. 3  If  there  are 
recent  adhesions,  carefully  disengage  the  intestine  with  the  finger  or  handle  of 
the  knife;  but  if  they  are  short,  and  the  intestine  and  sac  are  agglutinated  by 
old  adhesions  of  limited  extent,  cut  off  redundant  portions  of  the  sac.  ami  re- 
turn the  remainder  still  adhering  to  the  bowel.  Adhesions  at  the  mouth  of  the 
sac  are  separated  with  extreme  difficulty,  dilate  the  wound  to  the  point  of  at- 
tachment; slit  up  the  tendon  of  the  external  oblique;  if  convolutions  are  glued 
together,  separate  them. 

5.  Direct  inguinal  hernia,  2  (Fig.  405).  14  (Fig.  404).  (Fig. 
406);  forms  slowly,  appearing  first  as  a  ])roininence  behind  the  ex- 
ternal ring,  and  having  a  more  globular  shape  than  the  oblique:  the 
finger  enters  the  abtlominal  cavity  more  readily,  and  on  the  outer 
side  of  the  orifice  of  the  sac  the  internal  epigastric  artery,  13  (Fie. 
404),  is  felt  pulsating;  it  traverses  only  that  small  portion  of  the 
inguinal  canal  which  lies  immediately  behind  the  external  rinor, 
and  pushes  before  it  or  lacerates  the  conjoined  tendon,  7  (Fig. 
404),  and  the  pubic  portion  of  the  internal  abdominal  or  transversalis 
fascia,  6  (Fig.  404)  ;i  it  is  inclosed  between  the  epigastric  artery, 
edge  of  the  rectus,  16  (Fig.  404).  and  Poupart's  ligament.*  The 
truss  for  this  hernia  should  have  a  flat,  rounded,  or  oblately  oval  pad 
fitting  closely  between  the  edges  of  the  rectus  and  Poupart's  liga- 
ment, reaching  well  down  to  the  crest  of  the  pubis,  and  provided 
with  a  slight  notch  below  for  the  passage  of  the  cord.*  In  strangu- 
lated direct  hernia,  when  the  taxis  is  used,  direct  the  pressure  up- 
wards and  inwards,  instead  of  upwards  and  outwards.®  If  an  opera- 
tion becomes  necessary  for  relief,  make  an  incision  through  the  in- 
teguments along  the  middle  of  the  tumor  from  its  upper  to  its  lower 
part;  divide  the  fascia,  which  brings  into  view  the  sac;  the  stricture 
should  now  be  sought  for,  and,  whether  found  at  the  external  ring, 
or  higher  up,  or  within  the  sac,  divide  it  directly  upwards,  to  avoid 
the  epiirastric  artery. 

1  J.  Birkett.  -  F.  H.  Hamilton.  3  jj.  u.  Gross.  •»  J.  Wood. 

6  Sir  k.  Cooper. 

29 


450 


OPERATIVE  SURGERY. 


II.     FEMORAL  HERNIA. 

In  this  hernia  the  bowel  leaves  the  abdomen  at  the  groin,  under 
the  margin  of  the  broad  muscles  and  upon  tlie  anterior  border  of  the 
hip-bone,  immediately  at  the  inner  side  of  the  large  femoral  blood- 
vessels; after  passing  downwards  about  an  inch  or  less,  it  turns  for- 
wards to  the  fore  part  of  the  thigh,  at  the  saphenous  opening  in  the 
fascia  lata,  where  the  swelling  may  be  felt  and  seen.^ 

The  first  symptom  is  pain  about  the  stomach,  causing  nausea  on 
straightening  the  thigh,  relieved  on  taking  the  recumbent  position 
and  elevating  the  knees;  the  first  distinct  external  mark  is  a  general 
swelling  of  the  part,  easily  reducible  by  pressure,  descending  in  the 
erect  and  ascending  in  the  recumbent  posture;  next  a  small  circum- 
scribed tumor  appears,  the  size  of  the  finger's  end,  under  the  crural 
arch,  about  an  inch  on  the  outside  of  the  tuberosity  of  the  pubes,  in 
the  hollow  between  this  process  and  the  crural  artery  and  vein  (Fig. 
421).  As  the  tumor  enlarges  it  passes  forwards, and  often  turns  over 
the  anterior  edge  of  the  crural  arch;  the  swel- 
ling now  increases  more  laterally  so  as  to  as- 
sume an  oblong  shape,  the  longest  diameter 
being  transverse,  3  (Fig.  405) ;  in  the  female 
it  is  generally  very  movable,  and,  being  soft, 
resembles  a  gland;  it  appears  in  the  erect 
and  disappears  in  the  recumbent  posture,  di- 
lates when  the  patient  coughs,  is  elastic  and 
luiiform  when  it  contains  intestines,  and 
uives  a  gurgling  noise  when  it  returns  into 
I  he  abdomen;  when  it  contains  omentum  the 
surface  is  less  equal,  it  feels  doughy,  and 
gives  no  particular  sound  on  reduction. ^ 
Femoral  must  be  distinguished  from  inguinal 
hernia  by  its  position  below  Poupart's  liga- 
ment (Fig.  405);  from  abscess;  from  an  en- 
larged gland  and  an  enlargement  of  the  femoral  vein;  fi'om  tumors 
at  this  jioint.^ 

The  treatment  of  simple  hernia  must  be  by  a  well-adjusted  truss; 
the  truss  pad  must  protect  the  crural  ring  by  pressure  over  Poupart's 
ligament,  and  must  also  press  upon  and  fill  the  saphenous  opening, 
without  pressing  downward  so  as  to  obstruct  the  saphenous  vein. 
The  best  form  of  truss  pad  is  egg  shape,  with  the  small  end  down- 
wards, and  adapted  to  the  shape  of  the  saphenous  opening,  but 
rather  longer,  so  as  to  press  upon  Poupart's  ligament  with  its  broad 
end  above;  the  side  spring  is  exactly  in  the  centre;  the  pad  end  of 
1  Quain's  Anatomy.  2  gjr  A.  Cooper. 


Fig.  42 


THE  HERNIJE  OF   THE  ABDOMEN. 


451 


the  spring  is  bent  downward  in  a  large  curve,  to  j)ermit  the  pa- 
tient's thigh  to  bend  freely.  The  irredueible  hernia  is  best  sup- 
ported by  a  truss  with  a  hollow  pad  so  arranged  as  to  receive  the 
mass.^ 

Wlien  strangulation  occurs,  time  is  of  immense  consequence,  as 
mortification  occasionally  takes  place  in  less  than  twenty-foiu-  hours 
from  the  attack.  First  employ  taxis,  as  follows:  Give  an  anaesthetic, 
and  then  place  the  patient  on  the  back;  elevate  the  head,  shoulders, 
and  pelvis;  Ilex  the  legs  upon  the  thigh,  and  tlie  thighs  upon  the 
body,  and  rotate  the  affected  thigh  strongly  inwards;  draw  ilie  tu- 
mor downwards  and  slightly  inwards,  to  efface  the  angle  which  it 
forms  with  the  femoral  canal,  and  In-ing  it  opposite  the  external  ring; 
now  push  the  parts  directly  backwards,  to  get  them  out  of  reach  of  the 
lunated  edge  of  the  ring;  next  make  the  pressure  in  an  upward  direc- 
tion.^ If  taxis  fail,  ))roceed  to  operate.  The  coverings  of  a  femoral 
hernia  are:  skin,  1  (Fig.  422),  superficial  fascia,  2,  cribriform  fascia, 
3,  crural  sheath,  the  septutu  crurale, 
subserous  areolar  tissue,  sac.^  Select 
a  scalpel,  director,  and  hernia  knife. 
The  patient  being  placed  on  a  suitable 
table,  and  anesthetized,  empty  the 
bladder,  and  proceed  as  follows:  Make 
an  incision  down  to  the  supi'rficial  fas- 
cia from  an  inch  and  a  half  above  the 
crural  arch,  in  a  line  with  the  middle 
of  the  tumor,  downward  to  its  centre 
below  the  arch,  1  (Fig.  423);  make  a 
second  incision  from  the  inner  across  to  the  outer  side  of  the  tumor, 
2,  or  3,  so  that  the  form  of  the  double  incision  shall  be  somewhat 
crucial  (Fig.  423);  divide  the  superficial  fascia,  which  in  recent  her- 
nia is  very  thin  and  may  escape  notice,  or  in 
very  large  hernia  may  be  inseparably  united 
to  the  fascia  propria,  cribriform,  or  deep 
fascia;  the  latter  must  not  be  mistaken  for 
the  sac;  divide  this  fascia  longitudinally 
from  the  neck  to  the  fundus  of  the  sac  and 
expose  the  layer  of  fat  between  the  fascia 
propria  and  the  sac,  with  the  director  on 
which  the  entire  sac  is  laid  open;  introduce 
the  finL,'er  gently  into  the  sac,  between  the 
intestine  and  its  anterior  part,  on  which 
carry  the  hernia  knife  into  the  crural  sheath;  divide  the  sheath 
as  far  as  the  anterior  edge  of  the  crural  arch,  or  Poupart's  liga- 
1  S.  D.  Gross.  2  H.  Gray. 


Fig.  42 !. 


452  OPERATIVE  SURGERY. 

ment,  a  distance  not  exceeding  half  an  inch  in  a  small  hernia;  if 
the  intestines,  when  slightly  compressed,  cannot  be  readily  emptied, 
the  finger  must  be  passed  at  least  half  an  inch  higher  under  the 
posterior  edge  of  the  crural  arch  and  the  fascia  tranversalis,  and 
the  knife,  carried  within  the  stricture,  must  be  inclined  obliquely 
inward  and  upward,  at  right  angles  with  the  crural  arch;  divide 
the  stricture  in  that  direction  sufficiently  to  liberate  the  intestine  and 
admit  of  reduction.  In  very  large  hcrniae  it  is  advisable  to  divide 
the  stricture  external  to  the  sac,  but  in  small  hernise  the  risk  of 
gangrene  is  such  as  to  render  opening  the  sac  necessary ;  if  the  in- 
testines adhere  to  the  sac,  separate  them  with  great  caution  with 
the  finger,  or  if  the  adhesions  are  short  and  very  firm,  portions  of 
the  sac  must  be  cut  away  and  returned  into  the  abdomen  with  the 
intestine,  to  which  they  adhere,  and  the  stricture  must  also  be  di- 
vided with  great  care,  fibre  by  fibre.  The  after  treatment  is  the 
same  as  for  other  hernia. 

If  the  omentum  has  adhesions,  break  them  down  with  the  finger,  and  if  more  ' 
has  descended  than  can  be  easily  returned,  or  if  it 
has  become  hard  and  knotty,  cut  it  off  through  the 
sound  part,  which  will  be  known  by  the  bleeding 
vessels  ;  i  ligate  the  vessels,  and  return  the  mass  only 
to  the  mouth  of  the  sac;  when  the  protruded  parts 
have  been  returned,  close  the  wound  with  sutures 
and  adhesive  plaster,  and  apply  antiseptic  dress- 
ings with  suitable  compress  (Fig-  424). 

The  only  possilde  danger  which  can  be  met  with 
in  the  deep  incision  is  an  abnormal  distribution  of 
the  obturator  artery,  which,  if  it  arise  from  the  epi- 
gastric artery,  and  wind  close  to  the  inner  side  of 
the  neck  of  the  sac,  might  be  divided,  and  give  rise 
^^'         '  to  troublesome  hajmorrhage;  as  it  is  impossible  to 

ascertain  the  presence  of  the  vessel  in  that  position  beforehand,  and  as  it  is 
seldom  damaged  by  the  cautious  use  of  the  knife,  its  existence  may  be  ig- 
nored in  practice. 2 

III.    UMBILICAL   HERNIA. 

This  form  of  hernia  occurs  at  the  point  where  the  umbilical  ves- 
sels pass  through  the  abdominal  wall;  it  exists  anterior  to  the  period 
when  cicatrization  is  complete,  which  varies  in  different  infants,  but 
in  general  recjuires  several  months.^  When  the  parts  which  fill  the 
aperture  are  firmly  cicatrized,  this  point  of  the  wall  is  firmer  than 
surrounding  parts, ■*  owing  to  the  condensation  of  the  cicatrix  and  the 
peculiar  arrangement  of  the  fibres  of  the  transversalis  fascia^  (Fig. 
425). 

In  infants  the  protruding  viscus  pushes  before  it  that  portion  of  the  parietal 
1  Sir  A.  Cooper.      2  c.  Heath.     3  W.  Lawrence.     *  A.  Scarpa.     ^  Frorieps. 


THE  IIERNI^-E   OF   THE  ABDOMEN. 


453 


peritoneum  lyin;;  immediately  behind  tiic  aperture  in  the  linca  alba,  tlirough 
which  tiie  umbilical  vessels  enter  the  abdominal  cavity;  the  hernial  sac  thus 
formed,  before  the  closure  of  the  ring  is  ef- 
fected, may  pass  into  the  connective  tissue  of 
the  cord  itself  before  that  structure  has  sepa- 
rated; after  the  separation  of  the  cord  the  her- 
nial sac  may  be  protruded  in  conse(|uence  of 
the  umbilical  ajierture  remainin<jf  imperfectly 
closed,  when  it  is  covered  only  by  the  integu- 
ments; in  the  youth  the  hernia  may  escaji" 
throu-rh  a  partially  closed  ring,  which  it  di- 
lates by  continual  pressure;  in  the  adult  the 
fibres  of  the  linea  alba  may  become  separated 
by  stretching,  owing  to  the  pressure  within, 
and  the  hernia  escape  at  the  site  of  the  once  ^-^^^   ^.,- 

closed  ring,  or  in  its  vicinity  (Fig-  425 ).i 

The  liornia  begins  by  forming!:  a  soft,  projecting,  ovokl  tumor  at  the 
navel;  it  may  be  reduced  by  ))ressiire,  when  a  small  iiole  is  felt  with 
very  sharp  and  rigid  edges;  if  the  finger  is  removed  the  skin  eitlier 
remains  relaxed  in  the  fossa  of  the  navel,  or  is  slowly  projected  for- 
wards; as  the  disease  progresses,  the  protruding  viscus  descends 
lower  and  lower,  so  that  the  broadest  part  lies  below  the  mouth  of 
the  sac;  the  tumor  varies  much  in  form,  the  transverse  diameter 
being  sometimes  greater  than  the  vertical;  occasionally  it  is  pyriform, 
and  seems  suspended  by  a  stalk,  or  spread  out  like  a  mushroom; 
again,  its  base  is  nearly  as  large  as  its  bodj-;  in  infants  the  hernia 
usually  contains  intestines,  but  in  the  adult  omentum  is  generally 
added,  and  sometimes  the  stomach;  the  coverings,  usually  very  thin 
and  often  inseparably  united,  are  the  integument,  some  fat,  the  inter- 
nal abdominal  fascia,  the  sac ;  the  body  of  the  sac  is  usually  very 
delicate,  but  stronger  near  and  at  its  orifice,  around  which  the  tissues 
form  a  firm,  resisting,  unyielding  band;  the  mouih  of  the  sac  is 
often  large,  in  proportion  to  the  bulk  of  the  protrusion. ^  This  her- 
nia has  been  overlooked  in  very  cor[)ulent  persons,  and  proved  fatal 
by  strangulation.'^ 

In  the  infant,  persistent  efforts  must  be  made  to  close  the  opening  by  the  fol- 
lowing dressing:  Apply  a  flat  pad  of  any  soft  and  tolerably  lirm  niaterial.  moulded 
to  the  shape  of  the  parietes,  and  extending  beyond  the  margin  of  the  opening 
(Fig.  42fi);  maintain  it  in  position  by  adhesive  strips,  or 
b}'  a  broad  elastic  band  properly  padded;  remove  the  ap- 
paratus frecpiently  to  preserve  cleanliness  and  prevent 
chafing,  the  finger  being  applied  meantime  to  the  open- 
ing.3    Radical   cures   have   been   effected   by   operati<uis.  '''*^-  ■^2^' 

In    the   adult  this   hernia   is   best   retained  by  a  truss,  with   a  wooden  block 
slightl}'  convex  on  its  abdominal  surface,  and  secured  to  an  elastic  spring  en- 
circling the  body;  if  the  hernia  has  become  irreducible,  apply  a  hollow,  cup- 
'  J.  Birkett.  2  S.  D.  Gross.  »  T.  Ilohues. 


454 


OPERATIVE  SURGERY. 


Fig.  427. 


shaped,  well-padded  truss. i  Obstruction  from  accumulation  of  stercoraceous 
matters  frequently  occurs  in  irreducible  umbilical  hernia,  with  severe  constitu- 
tional disturbance,  but  without  positive  strangulation;  this  condition  is  best 
overcome  by  the  free  administration  of  aperient  enemeta.2  The  radical  cure 
has  been  effected  as  follows:  Press  the  finger  into  the  umbilical  opening,  and 
introduce  the  nozzle  of  a  hypodermic  syringe  (Fig.  427) 
tilled  with  tl.  ext.  quercus  alba,  and  inject  a  few  drops. 
In  moving  the  point  so  as  to  distribute  it  around  the 
neck  of  the  sac,  no  harm  is  done  if  a  small  quantity 
of  the  contents  gets  into  the  sac;^  retain  the  hernia 
surely  in  its  place  by  a  pad  and  bandage.3 

When  strangulation  occurs,  too  much  stress 
cannot  be  laid  upon  the  protracted  and  judici- 
ous employment  of  taxis,  owing  to  the  great 
fatality  of  operation  upon  tliis  hernia;  place  the 
patient  on  the  back;  give  an  anaesthetic;  as 
the  tumor  has  descended,  if  at  all  bulky,  draw  it  away  from  the 
ring,  press  its  contents  directly  upwards,  or  upwards  and  back- 
wards in  a  direction  opposite  to  that  of  the  displacement ;  should 
the  taxis  fail,  and  the  symptoms  not  be  urgent,  try  the  effects  of  a 
full  anodyne  and  cold  or  warm  ajiplications.^  These  efforts  having 
failed,  proceed  to  operate  antiscptically :  Select  a  scalpel  and  di- 
rector; bearing  in  mind  the  thinness  of  the  external  coverings,  par- 
ticularly in  recent  cases,  make  a  ^-shaped  incision  (Fig.  428),  the 
vertical  limb  being  carried  nearly  an  inch 
above  the  upper  extremity  of  the  tumor, 
directly  in  the  line  of  the  linea  alba;  raise 
successive  layers  on  the  director  down  to 
the  sac,  which  muse,  if  possible,  be  left 
intact,  owing  to  the  great  danger  of  fatal 
peritonitis,  if  it  is  divided.  Seek  the  seat 
of  stricture,  which  is  generally  found  at 
Fig.  428.  the  upper  margin  of  the  ring;  carry  the 

knife  upwards  upon  the  finger,  and  divide  the  stricture  to  the  requi- 
site extent;  draw  the  protruded  parts  somewhat  dowuAvards,  to  lib- 
erate them  from  their  confinement,  and  gently  replace  them  into  the 
abdomen,  —  first  bowel  and  then  omentum;  if  the  constriction  is 
within  the  sac,  the  latter  must^be  opened,  the  incision  being  as 
small  as  possible;  when  the  hernia  is  irreducible,  leave  the  protruded 
structures,  after  the  division  of  the  stricture,  in  their  extra-abdom- 
inal situntioii.i 


// 


1  S.  D.  Gross. 


2  J.  Birkett. 


3  J.  Heaton. 


viir. 

THE    RESPIRATORY    ORGANS 


CHAPTER   XLIII. 

THE  NOSE;  THE  NASAL  FOSS.E;  THE  ANTRUM. 
I.  THE  NOSE. 

Rhinoplasty,^  the  operation  for  restorinfj  the  nose,  consists  in 
the  ti'aiis[)lantation  of  liealtliy  skin  from  one  j)art  and  its  ailaptation 
to  the  formation  of  the  new  organ;  this  process  involves  making  a  new 
scar;  the  new  skin  has  been  taken  from  the  patient's  arm,  hand, 
face,  and  forehead.  The  latter  point,  being  most  accessible,  is  gen- 
erally preferred,  though  the  pedicle  is  necessarily  long,  and  must  be 
subjected  to  considerable  strangulation,  in  consequence  of  which 
sloughing  very  often  occurs.  The  rules  which  should  be  observed, 
in  performing  the  operation,  are  as  follows:^  (1)  The  patch  should 
be  taken  at  such  an  angle  as  will  diminish  as  much  as  jios.-ible  the 
twisting  of  the  pedicle;  (2)  the  patch  should 
be  placed  upon  a  raw  surface;  (3)  the  ex- 
posed space  from  whiih  the  patch  is  re- 
moved should  be  covered  in  part  by  the 
flap  raised  for  the  patch. 

In  general,  the  results  of  the  operation  are  not 
satisfactory,  owing  to  the  tendency  of  the  new  nose 
to  shrivel  and  collapse;  nor  have  the  ingenious 
methods  of  supporting  the  central  part,  as  by  a 
flap  from  the  upper  lip,  or  transplanting  a  terniiiiMl 
phalanx  of  liie  tmger,'-  proved  of  gieat  value.  If, 
however,  it  is  determined  to  undertake  an  opera- 
tion the  various  steps  to  be  taken  are  narrated  in 
the  following  cases  :  — 

1.  Restoration  of  the  apex  nasi  (Fig.  429).i 
The  anterior  edges  of  what  remained  of  both  ahc 
were  pared  and  made  straight;  an  incision  was  next  carried  upwards  on  both 
>  G.  Huck.  J  Hardee. 


Fk..  420. 


456 


OPERATIVE  SURGERY. 


sides  of  the  nose,  on  a  line  continuous  with  those  edges  to  the  inner  extremities 
of  both  eyebrows;  the  included  skin  was  dissected  off  the  nose,  and  left  attached 
above;  an  oiled  silk  pattern  of  the  denuded  nose  was  laid  on  the  forehead,  and 
a  larger  patch  dissected  up  and  turned  edgewise  on  its  pedicle,  and  applied  to 
the  exposed  surface  by  sutures  along  the  margins,  special  care  being  taken  to 
allow  no  strain  on  its  attachments;  the  patch  of  skin  taken  from  the  nose  was 
applied  to  the  lower  part  of  the  denuded  surface  on  the  forehead.  The  union 
of  these  flaps  left  prominent  tubercles  at  the  fold  of  their  pedicles  (Fig.  4.32); 
these  were  removed  by  curved  incisions  carried  half  around  at  the  base  of  each 
on  its  broadest  side,  unfi)lding  the  skin  and  cutting  away  the  redundant  mass 
(Fig.  4-32).  Union  of  these  relieved  the  deformity. 
2.  Closure  of  an  opening  i..to  the  superior  meatus  of  the  right  nasal 

fossa'  {Fig.  430);  —  the  skin 
at  the  margin  of  the  opening 
was  dissected  up  and  everted 
CL  with  great  care,  owing  to  the 
thinness  of  the  tissues;  a  pat- 
•  6  tern  of  the  opening  was  laid  on 
the  forehead  and  a  patch  dis- 
sected up,  b.  a,  c,  having  its 
base  in  such  position  as  to 
-fj  avoid  too  much  twisting  when 
transferred;  a  .strip  of  skin, 
c,  (/,  intervening  between  it  and 
the  opening  A\as  dissected  to 
make  room  for  the  patch,  but  was  left  attached  above  the  right  eyebrow  and 
used  to  cover  the  .--pace  made  by  tlie  flap:  the  patch  was  fixed  by  sutures,  and 
warm-water  dressings  applied.     Union  took  place  except  at  the  inner  canthus; 


Fig.  4.30. 


Fh..  431. 


4.32. 


this  was  closed  at  a  second  operation  by  raising  the  edges  of  the  skin  and  uniting 
them  by  sutures. 

3.  The  closure  of  a  foramen  (Fig.  431)  of  the  size  of  the  finger  has  been 
accomplished  bv  paring  the  edges  of  the  opening  and  everting  them;  next,  an 

1  G.  Buck. 


THE  NASAL  FOSSJiJ. 


4o7 


incision  was  made  from  a  to  b,  and  a  correspdiiiliiifij  incision  on  the  oppnsite 
side;  the  included  skin  was  dissected  up  an*l  reinoved,  but  bhoulU  liave  l)een 
reserved  to  cover  tlie  space  on  the 
forehead;  the  patt»rn  nf  the  space 
to  be  tilled  was  laid  mi  the  forehead, 
and  a  flap,  J",  e,  was  dissected  up, 
twisted  on  its  pedicle,  and  applied 
to  the  surface  exposed.  The  result 
was  sood  (!''{;•  4-^21.  An  elliptical 
patch  was  next  taken  from  the  ele- 
vated mass  caused  b}'  the  pedicle; 
next,  the  mouth  was  made  more 
symmetrical  by  extending  the  angle 
farther  towards  the  cheek  by  the 
method  given  (l'"'g-  307).     The  result 

was  favorable  (Fig.  433).  _.       ^oo 

^        '  Fig.  433. 

The  tr;insf)lantation  of  patches  dissected  np  witli  the  periosteum 
adherent  has  been  recominended,i  for  the  ])urpose  of  elevatins  a 
depressed  nose.  This  operation  '■^  consists  in  dissectinj:;  from  tlie 
dorsum  of  the  nose  two  flaps  by  an  incision 
along  its  centre,  and  transverse  incisions  at 
either  extremity;  the  next  step  is  to  dissect 
from  the  forehead  a  patch  which  will  cover  the 
denuded  surface,  removing  with  it  the  perios- 
teum; this  flap  is  then  turned  over  upon  the 
exposed  surface  with  the  integument  towards 
the  nasal  fossae,  and  the  periosteum  upward 
(Fig.  434);  the  two  lateral  flaps  are  then  laid 
upon  the  raw  surface  of  the  reflected  patch  and 
Fig.  434.  united  in  the  median  line. 


II.     THE    NAS.VL    FOSS.E. 

The  nasal  fossa?  open  widely  to  the  air  in  front  through  the  nos- 
trils, and  behind  into  the  pharynx. 

The  floor  is  horizontal,  but  the  roof  slopes 
forwards  and  backwards  from  the  cribriform 
plate,  making  the  vertical  depth  greatest  in 
the  middle:  tiie  outer  walls  are  made  irregular 
by  the  passages  which  the  turbinated  bones 
create,  and  numerous  openings  leading  to  the 
air  cells  ;  the  meatuses,  or  passages,  are  three 
in  niMTiber;  namely,  superior,  middle,  and  in- 
ferior; the  septinn  is  formed  chiefly  by  the 
perpendicular  plate  of  the  ethmoid  and  vo- 
mer.^ 


1  L.  Oilier. 


2  L.  Verneuil. 


Fig.  435. 

3  L.  Holden. 


458 


OPERATIVE   SURGERY. 


1.  Exploration  of  the  fossse  may  be  made  by  inspection  and  pal- 
pation. Inspection,  or  rhinoscopy,  may  be  anterior  or  posterior.  For 
anterior  inspection,  select  a  speculum  «,^  i,^  c^  (Fig-  435)  adapted 
to  the  case;  place  the  patient  in  a  good  light,  or  use  artificial  light, 
introduce  the  speculum  and  dilate  its  branches. 

The  parts  which  can  be  seen  are  the  interior  of  the  nostrils,  the  anterior  por- 
tion of  the  turbinated  bone,  a  portion  of  the  middle  concha,  and  a  portion  of 
tiie  floor  and  septum  of  the  nasal  cavity;  if  the  meatus  is  large  the  posterior 
wall  of  the  pharynx  and  even  the  orifices  of  the  Eustachian  tubes  may  be  ob- 
served.2 


For   posterior   inspection     (Fig.  437),   select  a   suitable   spatula 
and  mirror  (Fig.  453),  or  the  rhinoscope  (Fig.  4  3G)  *  ;  the  patient 


f 

Fig.  437.5  FiG.  438.6 

seated  in  front  of  a  good  light,  the  mouth  opened  widely,  the  tongue 
behind  the  lower  incisors,  virhere  it  may  be  depressed  by  the  spat- 
ula, pass  the  mirror  into  the  pharynx,  over  the  median  line  of  the 

1  Davis  &  Collins.  2  L.  Elsberg.  3  Thudichum.  4  p.  Sinirock. 

S  T.  R.  Brown.  ^  g.  Tiemann  &  Co. 


THE  NASAL  FOSS^. 


459 


tongue,  until  it  is  in  the  free  space  between  the  base  of  the  tonjrue, 
the  laryngeal  opening,  the  posterior  wall  of  the  pharynx,  and  the 
velum;  it  should  stand  on  the  right  or  left  side,  to  avoid  the  uvula, 
with  its  upper  edge  brought  close  to  the  posterior  wall  of  the  phar- 
ynx; the  problem  is  to  introduce  the  mirror  and  not  toueh  the  pa- 
tient ^  (Fig.  437). 

A  reflfctiiif;  mirror  adds  much  to  the  illumination  of  the  part's  (Fi^-  •ISS);  the 
haix!  mirror  beiiij^  introduced,  the  liglit  is  reHected  from  tiie  external  mirror 
upon  tile  intiTiial.-  Tlie  soft  pahite  often  seriously  olotructs  the  inspection  by 
falliiiic  backwards  against  the  pharyngeal  wall ;  this  can  only  be  overcome  in 
many  jiatients  by  a  hook, 3  or  the  elevator  of  the  mirror  (Fig.  4.3G).  The  parts 
to  be  seen  are  the  vault  of  the  pharyn.x,  the  septum  in  the  median  line,  the  pos- 
terior portion  of  the  middle  turbinated  bone,  and  part  of  the  middle  meatus;  part 
only  of  the  superior  and  inferior  turbinated  bones  are  seen;  the  posterior  sur- 
face of  the  velum  is  exposed,  and  laterally  the  orifices  of  the  Eustachian  tubes. 3 
Palpation  is  absolutely  necessary  to  render  conclusions  certain;  the  patient  sit- 
ting, pass  the  forelinger,  during  inspiration,  behind  the  velum,  and  turn  the 
point  upwards  as  far  as  the  posterior  nares;  the  points  examined  are,  the  pos- 
terior surface  of  the  velum,  the  septum,  and  the  pharyngeal  orifices  of  the 
Eustachian  tubes;  to  avoid  retching,  tlie  examinatinn  must  not  be  prolonged; 
points  that  cannot  be  reached  by  the  finger  may  be  palpated  with  the  laryngeal 
sound.  1 

2.  Medication  of  the  fossae  and  parts  posterior  may  be  effected 
by  the  spray  and  the  douche.  It  is  alleged  that  inflammation  of  the 
ear  may  be  caused  by  the  penetration  of  liquids  to  the  cavity  of  the 
middle  ear  through  the  Eustachian  tubes;  to  |)ruvent  the  occurrence 
of  this  accidiMit,  direct  the  jjatient  to  abstain  from  efforts  at  swallow- 
iui:,  by  drawing  out  the  tongue,  and  to  breathe  calmly  with  widely 
opened  mouth.^    The  spray  (Fig.  4.30).  medicated,  may  be  thrown  into 


^?., 


Fi<i.  43:).-»  Fig.  440.-» 

all  divisions  of  the  fossa?  through  the  anterior  meatus;  its  apjilication 
to  the  posterior  nares  and  parts  adjacent  is  effected  by  an  atomizer 
having  an  upward  cast,  introduced  behind  the  soft  palate  (Fig.  440). 
When  the  douche  is  used,  the  liquid  enters  one  nostril,  the  velum  is 
elevated  and  closely  approximated  to  the  posterior  pharyngeal  wall 

1  B.  Fraenkel.  2  A.  E.  Durham.  8  L.  FJsberg. 

*  Codman  &  Shurtleff. 


460 


OPERATIVE  SURGERY. 


so  that  the  nasal  cavity  is  closed  posteriorly  in  such  manner  that  the 
fluid  running  throui^h  the  posterior  nares  escapes  by  the  opposite  nos- 
tril and  is  received  into  a  vessel;  the  entire  nose  and  upper  part  of 
the  pharynx  is  thus  thoroughly  bathed. ^ 

The  little  vial  of  this  apparatus  (Fig.  4.'}9  and  Fitf.  440),  is  connected  with  the 
tube  b\'  means  of  a  metal  cap,  having  a  coarse  screw  thread  within  it  corre- 
sponding to  a  similar  thread  cast  upon  tiie  neck  of 
the  vial,  .so  that  tiie  atomizer  may  be  held  and  oper- 
ated with  one  hand  without  danger  that  the  vial  will 
be  detached  ; 
when  the  vial 
is  turned  into 
the  cap  so  as 
nearl_\    to   exclude   air,  the 
■spiav    1"  1  endered   exceed- 
mgh  (inc  ,  the  tubes  are  of 
sutli  l(  n^th  as  to  permit  the 
atcuuztd  Huid  to  be  applied 
directly    to    the    laryngeal 
and     pharyngeal     regions. 
The  nasal  douche   consists 
of   A,   reservoir,  to  contain' 
one  quart;  b,  leading  tube, 

three  feet  long;  c,  nozzle,  Fig.  441.2 

fitting  the  nostril  in  such  a  manner  that    liquid  cannot  pass  out- 
ward, nor  air  into  the  nostril;  d,  joint  formed  by  inserting  a  short 
glass  tube  within  the  rub-    ....  ..... 

ber  tubing,  at  which  nozzles 
of  different  sizes,  or  for 
different  patients,  may  be 
connected  without  loss  of 
time. 

A  c()n\  enicnt  douche  (Fig- 

4-12)  may  be  used  with  the 

water-])itcher.      To    start 

the  current,  put  the  weight 

and  about  half 

the  rubber  tube 

with  it  into  the  liquid;  the  reservoir  is  placed  higher 
"-than  the  head,  and  the  rubber  tube  is  grasped  near 
the  nozzle,  between  the  thumb  and  finger,  so  as  to 
contml  the  current  ;  the  nozzle  is  then  depressed 
enouuh  to  allow  a  little  of  the  liquid  to  escape,  there- 
by expelling  air  from  the  tube;  it  is  then  pressed 
gently  into  the  nostril,  and  the  grasp  slightly  relaxed, 
when  the  current  will  enter  and  fill  the  whole  cavity  of  the  nose,  and  escape  by 
tlie  opposite  nostril;  the  head  at  this  time  being  thrown  slightly  forward  over  a 
basin,  and  the  mouth  kept  open.  The  fountain  syringe  is  a  still  more  conven- 
ient douche.'' 

InsufHation   of  powdors   may  be  made  anteriorly  or  posteriorly; 
1  B.  Fraenkel.      2  Thudichum.      ^  Codman  &  Shurtleff.       *  L.  Elsberg. 


Fig.  442.3 


Fig.  443. 


THE  NASAL  FOSS^.  461 

the  former  requires  .a  tube  havinpj  a  chamber  for  the  powder;  the 
powder  may  bu  blown  out,  or  an  India-rubbt-r  ball,  by  which  tlie  pow- 
der is  driven  out  and  dirt'n?ed,  may  be  attached  (Fi^.  44;J);  but  any 
tube,  or  even  a  qniil,  with  a  bit  of  India-rubber  tube  attached,  may 
be  used  for  the  pnr[)o«e;'  the  latter  may  be  effected  liy  ^las^',  hard 
rubber  (Fig.  444);  or  metal  tubes,  curved  at  the  extremity,  intro- 


I'lG.  444.- 

duced  behind  the  soft  palate.  Fluids  may  be  applied  with  a  brush 
or  sponge,  the  brush  and  sponge-liolder  should  be  of  sullicient  lenj:th 
and  appropriate  curvature  for  making  the  applications  eitlier  into  the 
nostrils  or  through  the  mouth. ^ 

A  syringe,  with  a  suitably  curved  nozzle,  adapted  to  injections 
into  the  posterior  nares,  has  the  advantage  of  the  application  of 
fluids  directh'  to  the  diseased  parts,  without  the  danger  of  their  en- 
trance into  the  mi(hlle  ear  tlirough  the  Eustachian  tube.  If  the 
nozzle  has  several  perforations,  the  fluids  may  be  distributed  over  a 
large  nrea  as  a  coarse  spray. 

3.  Imperforate  nose  may  be  congenital,  when  it  is  caused  by  a 
membrane  stretched  across  the  nostrils,  or  by  firm  fibrous  tissue,  or 
by  simple  continuity  of  the  integument.  In  congenital  closure  the 
interference  with  respiration  and  sucking  often  requires  an  early 
operation;  in  most  cases  a  simple  incision  carefully  made  through 
the  o!)structing  membrane,  and  the  opening  maintained  l)y  strips  of 
lint,  or  a  short  elastic  canula,  is  sufficient ;  sometimes  it  may  be  de- 
sirable to  excise  a  portion  of  the  obstructing  tissue;  when  there  is 
no  indication  of 'the  opening  of  the  nostril,  the  adherent  parts  must 
be  gradually  and  cautiously  divided  until  the  nasal  canal  is  restored. 

4.  Occlusion  occurs  at  different  points.  Closure  of  the  nos- 
trils may  be  by  membrane  or  fibrous  tissue,  or  result  from  catarrhal 
inflammation  ; 8  or  one  ala,  or  both,  may  be  adherent  to  the  septum, 
or  even  to  the  upper  lip;  as  these  defects  interfere  with  respiration 
and  prevent  the  infant  from  sucking  freely,  they  demand  early  op- 
eration; make  a  simple  incision  of  sufficient  extent  carefully  through 
the  membrane,  or  excise  a  portion  and  keep  it  open  by  lint  or  canula 
until  the  cut  surfaces  are  healed.  Bending  of  the  cartilaginous  or 
bony  septum  causes  more  or  less  complete  closure  on  the  convex 
side.  If  the  cartilaginous  septum  alone  is  affected,  excise  a  portion 
on  the  convex  side  by  slicing  with  a  narrow  probe-pointed  bistoury, 
care  being  taken  to  avoid  perforating  it.4 

1  H.  Knapp.  -  Tieiiiann  &  Co.  3  L.  Elsberg.  ••  S.  D.  Gross. 


Fig.  445. 


462  OPERATIVE  SURGERY. 

The  bony  septum  may  be  fractured  and  made  straight  as  fol- 
lows:^ Introduce  a  pair  of  smooth,  thiii-bladed  forceps,  grasp  the 
septum  and  close  tlie  blades;  the  septum  is  fractured  and  the  frag- 
ments are  brouglit  into  a 
straight  position  ;  a  metal 
clamp  witli  tliin  blades  is 
now  introduced  and  tight- 
ened ;  this  apparatus  is  re- 
tained as  a  splint  until  the  bones  unite,  which  usually  occurs  in  two 
weeks;  the  clamp  must  not  be  too  tight  (Fig.  445). 

Narrowing,  or  stenosis,  of  the  deeper  passages  may  be  suflSciently  overcome 
in  infants  by  the  use  of  hollow  bougies  as  dilators,  or,  in  more  severe  cases,  b\' 
forcible  distention  by  means  of  a  pair  of  thin,  long-armed  forceps,  by  the  open- 
ing of  which  the  abnormally  approximated  bones  are  separated."^  Bony  closure 
of  the  posterior  nares  may  exist  from  a  continuation  of  the  free  posterior  border 
of  the  palate  bones  upward  and  backward;  this  occlusion  maj-  be  overcome  by 
perforation  of  the  bony  plate. ^ 

5.  Haemorrhage,  epistaxis,  is  of  very  common  occurrence,  owing 
to  the  immense  distribution  of  blood-vessels  throughout  the  cavities, 
and  the  existence  of  cavernous  bodies  between  the  periosteum  and 
mucous  membrane  on  the  turbinated  bones;  bleeding  maybe  spon- 
taneous, or  result  from  injury,  and  when  severe  there  is  a  rupture  of 
vessels;  the  diagnosis  is  easy  when  the  haemorrhage  continues,  but 
if  it  have  ceased,  an  examination  of  the  nasal  passages,  and  the  his- 
tory of  the  attack,  determines  its  origin.^  In  the  treatment,  discrim- 
ination and  judgment  are  as  frequently  required  as  skill,  for  it  is  as 
important  to  decide  wisely  as  to  the  necessit}'  of  arrest,  as  to  devise 
and  apply  the  best  means  of  effecting  it;  in  many  cases,  the  condi- 
tions which  have  given  rise  to  the  bleeding  require  treatment,  rather 
than  the  incidental  and  temporary  flow  of  blood ;  the  non-recur- 
rence of  periodical  or  habitual  epistaxis  may  betoken  the  approach 
of  danger  ;  in  others,  the  sudden  arrest  of  the  bleeding  by  surgical 
interference  may  be  followed  by  symptoms  of  the  gravest  import.^ 
In  general,  the  hsemorrhage  should  be  arrested  when  it  seems  to  be 
dangerous,  or  when,  by  its  severity  or  the  frequency  of  its  recur- 
rence, it  begins  to  produce  symptoms  of  acute  or  chronic  anaemia. 
The  end  sought  in  treatment  is  the  formation  of  a  coagulum.  The 
simple  measures  should  first  be  employed  ;  place  the  patient  in  the 
sitting  posture,  the  head  inclined  slightly  forward,  remove  all  articles 
from  the  neck  which  pi-event  the  free  flow  of  blood ;  secure  the  most 
perfect  possible  state  of  rest  of  mind  and  body,  and  encourage  quiet 
respiration  without  speaking,  or  blowing  the  nose.^  The  simple 
means  are  cold  to  the  nose  and  forehead,  or  to  the  back  of  the  neck, 

1  W.  Adams.      2  Hopp^;  B.  Fraenkel.      3  B.  Fraenkel.      4  a.  E.  Durham. 


THE  NASAL  FOSS^. 


463 


Fig.  44G.C 


elevation  of  the  arms  above  the  head,  astringent  injections  as  of 
aliun,  tannin,  zinci  sulph.,  astringent  fpray,  mustard  foot-batlis.  As 
in  a  hirge  nuniher  of  cases,  tlie  bleeding  spot  is  near  tlie  anterior 
and  lower  border  of  the  septum, ^  the  bleeding  may  often  be  arrested 
by  pressing  the  ala  of  the  affected  side  against  the  septum  in  such  a 
manner  as  to  close  the  nostril,  and  the  front  and  upper  part  of  the 
nose;  or  the  finger  may  be  api)lied  directly  in  the  nostril;  or  a 
compress  of  lint,  tied  with  a  string  with  which  to  remove  it,  may 
be  introduced  into  the  nostril;'^  wicks  or  strips  of  linen  may  be 
introduced  through  the  nose  to  the  pharynx, ^  and  llu-y  may  be 
sprinkled  with  tannin,''  or  dipped  in  persulphate  of  iron,^  to  increase 
their  styptic  (pialitics.  If  these  measures  fail,  either  compression 
must  be  made  by  the  rhineurynter,  or  the  posterior  nares  must  be 
plugged  ;    the   former  is   a  simple   intlative  balloon  which   is  intro- 

E^gdlftiluced  into  the 
nostril  while 
empty,  and 
then  inflated 
by  means  of  a 
flexible  tube,  and  maintained  full  by  closure  of 
a  stop-cock.  The  posterior  nares  are  plugged 
by  means  of  the  catheter  tube  (Fig.  44G).''  In- 
troduce the  tube,  with  spring  withdrawn,  along  the  floor  of  the 
nose,   G   (Fig.  44  7),   until    the   pharynx   is   reached;    advance    the 

spring,     which,     after     passing 
around    the   velum,    appears   in 
^A  the  mouth;   attach  a  thread   to 

the  tampon 
through  the  small 
eye  in  the  button 
at  the  end  of  the 
spring,  and  with- 
draw it ;  the  t£vmpon,  8 
(Fig  447),  passes  back- 
ward behind  the  soft 
palate;  as  the  tube  is 
witlidrawn  the  plug  is  lodged  in  the 
posterior  nares ;  the  threads  of  the  tam- 
pon must  be  brought  out,  one  from 
the  mouth  and  the  other  from  the  nose, 
and  knotted;  when  the  tampon  is  removed,  untie  the  threads  and 
draw  it  backwards  through  the  mouth. 

1  A.  E.  Durham.     "-  B.  Fraenkel.      3  Thompson.     *  Curtin.      »  L.  Elsberg. 
«  G.  Tiemanu  &  Co.     '  Belloc. 


Fig.  447. 


464  OPERATIVE  SURGERY. 

6.  Foreign  bodies  may  be  introduced,  or  may  form  in  the  nasal 
cavities;  the  former  CTiibrace  all  substances  which  may  be  forced 
through  the  anterior  or  posterior  meatus,  and  the  latter  is  confined 
to  concretions,  calculi,  which  form  around  some  nucleus.  The  symp- 
toms vary  ;  these  substances  mny  remain  long  in  the  nasal  cavities 
without  causing  any  trouble;  but,  in  general,  their  immediate  effect 
is  circumscribed  inflammation,  with  purulent,  bloody,  and  often 
fetid,  secretions.  The  diagnosis  is  made  out  from  the  history  and 
exploration ;  if  the  history  is  doubtful,  inspect  the  cavities,  re- 
membering that  the  foreign  body  may  be  covered  with  secretions; 
finally,  explore  with  the  probe,  distinguishing  by  the  sensation, 
sound,  and  mobility,  between  the  movable  body  and  the  bone.^ 
Early  removal  must  follow  detection  of  the  body.  Sneezing  and  the 
douche  are  sometimes  effective;  the  most  convenient  instruments  are 
thin,  short,  straight,  dressing  forceps,  and  small  scoops;  care  is  requi- 
site in  seizing  the  body  lest  it  be  pushed  more  deeply  into  the 
cavity.^ 

7.  Abscess  forms  in  the  epidermoid  lining  of  the  nose,  the  result 
of  inflammation,  either  spontaneous  or  traumatic;  the  course  of  this 
affection  is  usually  rapid,  and  the  abscess  opens  at  the  end  of  a  few 
days,  with  relief;  it  may  assume  a  phlegmonous  character,  attended 
with  great  swelling  of  the  mucous  membrane,  oedematous  swelling  of 
the  external  parts  of  the  nose  and  adjacent  parts  of  the  face  and 
lower  eyelids,  severe  pain  and  fever,  and  terminate  in  wide-spread 
suppuration;  or  the  inflammation  may  even  reach  the  meninges  of 
the  brain. ^  The  treatment  of  the  mild  form  should  be  cold,  leeching, 
and  early  opening  of  the  abscess.  The  phlegmonous  variety  requires 
active  measures  to  promote  local  suj)puration,  as  applications  of 
warm  vapor,  cloths  wrung  out  of  hot  water,  poultices,  free  incisions 
where  the  skin  is  tense,  and  early  opening  of  the  abscess. ^  Acute 
abscess  may  form  in  the  septum  and  give  rise  to  severe  pain  and 
high  fever;  the  inflammation  may  extend  to  the  upper  lip  and  to  the 
frontal  sinuses  and  lachrymal  passages;  the  surface  is  red,  shining, 
tender  on  pressure,  has  an  extensive  base.  In  the  treatment  prevent 
the  formation  of  pus  if  possible;  but  failing,  open  the  abscess  by 
free  incision  as  soon  as  it  is  formed,  followed  by  soothing  and  astrin- 
gent washes. 2  Chronic  abscess  commences  often  without  assignable 
cause,  and  progresses  insidiously;  it  may  be  mistaken  for  polypus  or 
thickening  of  the  mucous  membrane ;  in  a  majority  of  cases  it  ter- 
minates in  perforation  of  the  septum;  the  abscess  must  be  opened 
early,  and  perforation  pi-evented  by  injections  of  detergent  solutions, 
as  arg.  nit.,  zinci  sulph.,  acid  carbol. 

8.  Papillomata  *  consist  of  immature  connective  tissue  having  a 
1  B.  Fiaenkel.         2  A.  E.  Durham.        3  w.  Parker.         *  M.  Mackenzie. 


THE  NASAL   FOSS.E. 


4  Go 


papilliiiy  arrangi'iiumt  with  iniprisoiicil  jyoitioiis  of  iniifi[)arou.s 
glands;  tliey  arc  y;ciiL'rally  situated  on  the  inner  surface  of  the  ala3, 
are  nu-t  with  more  frequently  in  children,  cause  irritation,  but  do 
not  attiiin  sufHcient  size  to  cause  much  embarrassment  of  respiration 
or  altoiation  of  the  voice;  they  should  be  removed  with  curved  scis- 
sors, or  twisted  o<f  with  forceps. 

9.  Mucous  polypi  '  are  localized  hypertrophies,  or  outgrowths  of 
the  niucoiis  menihrani;  and  submucous  tissue;  in  consistence  they 
are  soft,  p"ilpy,  and  somewhat  elastic;  in  color,  pale,  yellowish, 
grayish,  or  slightly  greenish;  in  apjjearance,  shining  and  semi-trans- 
parent; they  are,  as  a  rule,  peduncidated  and  pendulous,  and  more 
or  less  niovalile,  single  or  mulli|)le,  pear-shaped,  or  irregularly  lobu- 
lated  to  fit  thy  cavities  in  which  they  lie. 

Tliey  rarely,  if  ever,  spring  from  the  imicous  meiubrane  covering  the  septum; 
are  nu)st  frefiucntly  connected  with  tiiat  which  covers  the  su])erior  and  middle 
turbinated  bones,  and  lines  the  superior  and  middle  meatus,  but  may  arise  in  the 
lower  meatus,  or  be  attaclied  to  the  inferior  turbinated  bone,  or  the  roof  of  tlie 
nose,  the  ethmoidal  cells,  or  even  the  frontal  sinuses;  in  the  nostril  they  tend 
to  fill  the  cavit}'  and  protrude  forwards  or  backwards,  sometimes  expanding 
the  ala'  and  even  the  nasal  processes  of  the  superior  maxilla,  or  hanging  down 
beliind  the  uvida  into  the  pharynx. 

The  symptoms  are  fullness  and  weight  about  the  affected  nostril, 
Avhich  gradually  become  so  much  obstructed  as  to  interfere  with  res- 
jiiralion  and  the  voice,  especially  during  damp  weather,  when  the 
growths  become  fuller  and  paler  in  color  ; 
the  diagnosis  is  generally  easily  made  with 
the  nasal  speculum  and  rhinoscope.  The 
treatment  is  removal.  Evulsion  is  the 
most  simple,  certain,  and  rapid  method  of 
removal,  and  may  be  performed  with  for- 
ceps or  the  snare.  1  The  forceps  should 
1)(!  strong,  short,  with  blades  slightly  bent 
laterally,  grooved  longitudinally,  and  well 
serrated  along  their  edges  (Fig.  448)  :  if  the 
polypus  is  situated  posteriorly,  and  must 
be  removed  through  the  mouth,  the  forceps 
must  have  the  proper  curve  (Fig.  449).^ 

Anajsthetics  are  often  required,  especially  in 
delicate  women,  but  there  are  marked  advantages 
when  the  patient  is  able  to  submit  without  this 
agent,  such  as  clearing  the  nasal  passages,  and 
Fig.  448.'''  preventing  the  entrance  of  Idood  iulo  the  air-pas- 
sages, l  Great  care  must  be  exercised  in  ap|)lying 
the  forceps  and  removing  the  growths  to  avoid  the  risk  of  inllicling  serious 

1  M.  Mackenzie.  2  a.  E.  Dinham.  8  (j.  Tieniann  &  Co. 

30 


Fk:.  449.8 


466  OPERATIVE  SURGERY. 

damage  by  tearing  away  unnecessarily  the  mucous  membrane  or  the  turbinated 
bones.  1 

Place  the  patient  in  a  chaii",  in  front  of  a  good  light,  with  the  head 
thrown  back  and  supported  by  an  assistant,  who  also  elevates  the 
tip  of  the  nose,  as  the  external  opening  of  the  nostril  is  on  a  lower 
level  than  the  floor  of  the  nasal  cavity;  introduce  the  blades  of  the 
forceps  closed  into  the  nose;  glide  them  along  the  floor  or  septum 
until  their  extremities  have  reached  and  passed  to  some  extent  the 
visible  portion  of  the  polypus;  open  the  blades  in  a  vertical  or  ob- 
lique direction,  turned  upwards  and  outwards  so  as  to  include  as 
much  as  possible  of  the  growth  ;  seize  it  firmly,  and  tear  it  from 
its  attachments  by  traction  and  rotation  of  the  forceps  on  their 
lonof  axis;  if  the  polypus  yields  without  being  detached,  grasp  it 
close  to  its  roots  with  a  second  forceps,  and  twist  it  off  at  its  origin.^ 
When  the  growth  is  situated  far  back,  pass  the  forefinger  of  the  left 
hand  round  the  soft  palate  into  the  posterior  nares,  and  guide  the 
forceps,  introduced  from  the  front,  to  the  peduncle;  if  the  polypus 
is  very  large,  and  attached  at  several  points,  extract  it  in  successive 
portions. 2  If  the  polypus  is  situated  posteriorly  and  hangs  down 
into  the  pharj'nx,  it  may  be  seized  by  properly-curved  forceps  passed 
through  the  mouth,  and  behind  the  soft  palate,^  or  it  may  be  de- 
tached by  forceps  introduced  through  the  nostril  and  pushed  back- 
ward into  the  pharynx. ^  The  thermo-cautery  may  be  used,  when 
the  growth  is  easily  accessible,  for  the  destruction  of  the  base. 
The  snare  best  adapted  for  evulsion  (Fig.  450)*  consists  of  the  nasal 

portion,  the  ring, 
the  cross-piece, 
and  a  quadrang- 
ular stem  ;  there 
is  a  hinge  which 
Fig.  450.5  ^"^       gives   any  angle 

to  the  shaft;  in 
prejiaring  it,  pass  a  wire  through  the  doubly-perforated  extremity, 
and  through  two  small  holes,  and  attach  it  on  either  side  with  the 
sliding  cross  piece,  making  a  loop  beyond  the  bulbous  end;  in  using 
it,  advance  the  cross-piece  as  far  as  possible,  which  projects  the  loop; 
introduce  this  loop  into  the  nostrils  with  the  end  of  the  shaft,  and 
pass  it  over  the  polypus  to  its  pedicle;  draw  the  cross-piece  down  the 
shaft,  fixing  the  loop  firmly  to  the  growth,  then  twist  and  pull  until 
the  growth  is  detached. ^  Polypi  have  been  removed  by  the  forefin- 
gers, one  pressing  through  the  nostril  anteriorly,  and  the  other  pos- 
teriorly, until  it  is  detached.^  The  galvano-ecraseur  may  be  used;'' 
1  A.  E.  Durham.  2  M.  Mackenzie.  8  J.  Syme.  4  j.  h.  Hilton. 

6  Codman  &  ShurtlefE.  6  s.  D.  Gross.  '"^  Thudichum. 


THE  NASAL  FOSSAE. 


467 


the  operation  is  attended  witli  little  pain,  and  there  is  no  risk  of 
hieniorrhage ;  but  as  the  wire  can  rarely  he  adjusted  to  the  pedicle, 
and  no  traction  is  made,  the  growth  has  to  be  removed  in  slices.^ 
After  tlie  removal,  llie  ha-morrliage  usually  ceases  spontaneously, 
but  may  require  the  application  of  ice,  or  even  tlie  [)lu<r<rin(»  of  the 
nostrils;  injections  of  astringents,  or  insufflation  of  tannic  acid  or 
other  powders  are  useful  in  removing  remaining  portions  of  the 
growth.'' 

10.  The  fibrous  polypus  i  springs  from  the  periosteum,  and  is 
con)po.sed  of  bundles  of  compact  connective  tissue  interspersed  by 
elongated  nuclei;  some  are  of  almost  cartilaginous  hardness,  and  the 
softer  varieties  are  very  vascular  ;  it  may  grow  from  any  part  of  the 
walls  of  the  nasal  fossa,  but  more  frecpiently  it  is  attached  to  the  bas- 
ilar process  at  the  base  of  the  skull,  and  first  appears  in  the  pharynx 
as  a  naso-pharyngeal  polypus;  it  is  usually  distinctly  pedunculated, 
but  forms  adhesions  to  opjjosing  surfaces  ;  in  aj)pearance,  it  is  a  red, 
fU'shy-looking  mass,  hard,  and  resisting  to  the  ])robe,  tender,  liable  to 
blied,  frequently  ulcerated,  with  a  purulent  and  even  fetid  discharge; 
tlie  growth  at  first  causes  the  ordinary  symptoms  of  mucous  polypus, 
as  nasal  obstruction,  epistaxis,  mucous  discharge;  but  as  it  spreads 
it  causes  absorption  and  displacement  of  the  surrounding  structures, 
pushes  the  septum  to  one  side,  penetrates  the  orbit,  extrudes  the 
eye-balls,  forces  the  walls  of  the  antrum  outwards,  causing  the  frog- 
face  deformity,  and  even  enters  the  cranium  and  compresses  the 
brain  ;  the  treatment  is  thorough  removal  at  the  earliest  stage  prac- 
ticable, and  the  result  is  generally  favorable.  E.xtirpation  may  some- 
times be  effected  by  the  forceps,  ligature,  or  galvano-caiistic,  at  an 
early  stage,  when  the  growth  has  a  small  pedicle  within  easy  reach. 
If  the  tumor  is  larger,  it  may  suffice  to  cut  through  the  ahe  of  the  nose 
along  their  junction  with  the  cheek,  1,  2  (Fig.  4ol),  the  nasal  jiro- 
cesses  of  the  maxillaj  and  the  skin  with  the  nui- 
cous  membrane  covering  them,  and  the  septum; 
turn  the  nose  upwards,  remove  the  growths, 
and  replace  the  parts; '^  or  the  nose  may  be 
divided  above  by  a  p  incision,  1,  2,  1  (Fig. 
451),  and  turned  downwards.^  If  still  larger, 
excise  the  nasal  bone  thus:^  make  an  incision 
from  the  junction  of  the  frontal  anil  nasal 
bones,  2,  3  (Fig.  451),  vertically  downwards 
along  the  mesial  line  of  the  nose  to  the  upper 
margin  of  the  alar  cartilage,  thence  outwards 
to  the  cheek,  1  (Fig.  451)  dis.sect  off  this  triangular  flap,  avoiding  the 
periosteum,  and  sever  the  alar  cartilage  from  its  attachments  to  the 

1  M.  Mackenzie.        2  a.  E.  Diu-liain.        s  L.  Oilier.        *  Von  Lantrenbeck. 


468  OPERATIVE  SURGERY. 

bone  superiorly;  separate  the  nasal  bone  from  its  fellow  on  the  oppo- 
site side  by  bone  nippers,  and  in  the  same  manner  cut  away  the  nasal 
process  of  the  superior  maxillary  from  the  body  ;  with  an  elevator, 
raise  the  quadrilateral  plate  of  bone  upward  so  as  to  lay  open  the 
whole  upper  part  of  the  nasal  cavity  ;  remove  the  tumor  through  the 
gap  thus  made,  either  by  the  knife  or  forceps ;  replace  the  parts 
disturbed  accurately. 

The  larger  tumors  may  also  be  removed  tlirough  an  incision  of  the  hard  pal- 
ate i  thus:  divide  tiie  soft  palate  throunhout  its  whole  extent  and  thickness  in 
the  middle  line;  next  make  a  longitudinal  incision  along  the  posterior  half  of 
the  hard  palate  down  to  the  bone,  and  two  others  obliquely  outwards,  one  on 
each  side,  to  the  alveolar  process;  raise  these  flaps  from  the  bone  and  reflect 
tiieni  outwards;  perforate  the  palate  and  cut  it  away  with  forceps;  divide  the 
periosteum  and  mucous  membrane  of  the  floor  of  the  nose  and  turn  the  flaps 
aside;  excise  as  much  of  the  vomer  as  may  be  necessary  to  expose  the  tumor, 
which  may  now  be  readily  removed,  unless  of  large  size  and  too  extensively 
attached;  the  opening  in  the  palate  should  not  be  closed  for  some  time  after  the 
operation,  when  staphyloraphy  may  be  performed. 

The  largest  growths  require  excision  of  the  upper  jaw;^  extract 
the  lirst  incisor  of  the  side  affected;  make  an  incision  from  the  inner 
canthu.";,  along  the  side  of  the  nose  and  through  the  lip,  in  the  me- 
dian line,  1  (Fig.  452),  a  second  incision  2,  (Fig.  452),  may  be  required 
from  the  malar  bone  to  the  angle  of  the  mouth  or  ala;  or  3  (Fig. 
,>^*^^^*% 7 1  ■  ■  4^-)»  *^°  the  inner  canthus;  dissect  up  the 
"^^v  /^'  flap  thus  formed  and  expose  the  bone;  with 
forceps  separate  the  bone  in  the  median  line 
from  its  fellow;  divide  the  portion  between 
the  nostril  and  the  inner  margin  of  the  orbit; 
saw  tlirough  the  malar  tuberosity,  and  divide 
the  soft  palate  in  the  median  line :  carefully 
free  the  bone  from  the  superior  maxillary 
nerve  and  other  soft  parts;  separate  the  or- 
Fir  459^^**"  bital  plate,  when  it  can  be  saved,  with  cut- 
ting forceps,  and  with  lion  forceps  seize  the 
mass  and  twist  it  out;  remove  the  growth,  apply  the  actual  cautery 
to  its  attachments  to  arrest  lijemorrhage  and  destroy  the  remnants  of 
the  tumor;  carefully  readjust  the  parts  and  retain  them  with  sutures. 

11.  Cartilaginous  tumors  spring  from  the  cartilaginous  septum 
and  the  frontal  and  ethmoidal  cells;  as  a  rule  they  are  hard,  but  may 
be  quite  soft;  are  never  pedunculated  and  seldom  ulcerate;  when  at- 
tached to  the  septum  or  fosste,  and  accessible,  they  must  be  removed, 
as  described. 3 

12.  Osseous  tumors  may  be  exostoses,  or  ossified,  cartilaginous, 
sarcomatous  growths,  or  independent  bony  tumors;  they  are  recog- 

1  E.  Nelaton.  2  Flaubert ;  Tatum.  3  j\i.  Mackenzie. 


THE  ANTRUM.  469 

nizod  by  tlicii*  liardnoss;  exostoses  must  be  cut  off,  but  the  osseous 
tumor  must  be  fully  exposed  by  methods  given,  and  extirpated.^ 
The  burr  of  the  dental  engine  is  a  very  effective  instrument  for 
removing  the  base  of  the  tumur.^ 

13.  Sarcomata  are  the  reju-esentatives  of  the  quasi-malignant 
growths;  they  are  attached  to  tiie  sides  of  the  nasal  cavities,  are  hard 
or  soft;  they  may  result  from  the  degeneration  of  polypi,  or  spring 
up  as  sarcoma;  they  appear  as  fleshy,  lobulated,  succulent  tumors, 
bright  red,  or  of  a  dirty  ashen  hue,  readily  softening,  ulcerating, 
bleeding,  and  attended  by  fetid  discharges  and  severe  pain ;  they 
must  be  removed,  and  generally  by  exsection  of  the  upper  jaw.^ 

14.  Cancer  originating  in  the  nasal  fossa?  is  rare,  and  should  not 
be  removed.^ 

III.    THE    ANTRUM. 

The  antrum,*  maxillary  sinus,  is  a  large  cavity  in  the  body  of  the 
superior  maxilla,  lying  above  the  molar  teeth  and  below  the  orbital 
plate,  lined  in  the  fresh  state  by  mucous  membrane,  and  communi- 
cating with  the  middle  meatus  of  the  nose.^  The  relations  of  the 
antrum  to  the  teeth  vary  extremely ;  it  may  extend  so  as  to  be  in 
immediate  relation  to  all  of  the  teeth  of  the  true  maxilla,  or  may  be 
so  contracted  as  to  correspond  with  only  two  or  three  of  the  central 
ones;  occasionally  a  root  or  roots  of  the  first  molar  extend  into  the 
cavity,  free  of  any  bony  covering,  and  merely  overlaid  by  the  mu- 
cous membrane  lining  the  sinus;  the  orifice  which,  opens  into  the 
middle  meatus  varies  from  the  size  of  a  probe  to  that  of  the  end  of 
a  little  finircr,  2  (Fig.  447).6 

1.  Dropsy  may  be  due  to  the  extension  of  nasal  catarrh  to  the 
mucous  membrane  of  the  antrum^  or  to  the  formation  of  cysts.*  It 
appears  as  a  gradual  and  generally  painless  expansion  of  the  bone, 
and  may  encroach  upon  the  nose,  the  orbit,  or  cavity  of  the 
mouth,  causing  obstruction  and  deformity.^  For  correct  diagnosis 
perforations  may  be  necessary.  The  treatment  is  evacuation  of  the 
contents  by  puncture  at  the  most  dependent  part,  or  where  bulging 
appears;^*'  in  some  cases  the  front  wall  of  the  antrum  must  be  cut 
away  V)y  raising  the  cheek  at  that  point  without  dividing  the  lip,'^ 
the  cavity  cleansed  and  iodine  applied  to  its  walls,  3  (Fig.  452). 

2.  Abscess*^  results,  in  the  majority  of  cases,  from  dental  caries 
or  alveolar  a])scess;  there  is  a  dull  aching  pain  in  the  (;heek,  with 
heat,  redness,  and  fullness  of  the  soft  parts  externally;  there  may  at 
first  be  purulent  discharge  from  the  nose,  but  the  swelling  of  the 
mucous   membrane   soon  closes  the   sinus;    there  is  now  throbbing 

1  A.  E.  Duvliam.      2  j.  g.  Cohon.  ^  ;\[.  .Mackenzie.         •*  lliirlimore. 

5  Qnain's  Aiiat.        *•  S.  .1.  A.  Salter.  "  I?.  Fraenkel.  8  M.  Giraldi?3. 

»  T.  Bryant.  "  S.  D.  Gross.  "  W.  Ferfiusson. 


470  OPERATIVE  SURGERY. 

pain,  rigors,  fever,  expansion  of  the  jaw,  elevation  of  the  malar 
bones,  projection  of  the  molar  teeth,  depression  of  the  arch  of  the 
palate  bone ;  the  finger  seldom  fails  to  detect  the  fluctuation,  but  ex- 
ploration may  be  made  with  a  fine  trocar  and  canula ;  the  pus  may- 
escape  into  the  nose,  through  the  cheek,  into  an  alveolar  cavity, 
through  the  floor  of  the  orbit;  before  the  abscess  has  formed,  and 
when  as  yet  it  is  only  imminent,  remove  any  carious  tooth  or  teeth 
in  the  neighborhood  and  apply  leeches  and  fomentations ;  when  pus 
has  formed,  extract  all  carious  teeth  from  the  maxilla  involved,  and 
if  the  pus  is  discharged  from  the  cavity  of  either,  enlarge  the  open- 
ing sufficiently  to  give  free  exit  to  the  pus  in  the  antrum;  if  there  is 
no  carious  tooth,  proceed  as  follows:  Perforate  the  antrum  by  ex- 
tracting the  first  permanent  molar  tooth,  and  passing  a  trocar  into 
the  cavity  through  its  socket;  the  forefinger  should  be  extended  on 
the  shaft  of  the  trocar  as  a  guard,  and  the  instruments  pressed  for- 
wards with  an  even,  rotating  motion ;  avoid  the  sudden  giving  away 
of  the  wall  of  the  antrum  and  the  plunge  of  the  trocar  through  the 
wall  of  the  orbit ;  if  the  teeth  of  the  affected  side  have  been  long 
removed,  the  antrum  is  more  readily  perforated  at  the  base  of  the 
malar  process  of  the  maxillary  bone,  over  the  region  formerly  occu- 
pied by  the  second  or  third  molar  tooth,  by  dividing  the  mucous 
membrane  and  employing  a  large  trocar  or  a  strong  pair  of  scissors;  ^ 
when  the  antrum  is  opened,  wash  it  out  thoroughly  with  warm  water, 
followed  by  cai-bolic  acid  solutions ;  the  entrance  of  food  must  be 
prevented  by  plugs  of  hard  rubber,  or  by  a  plate  fitted  to  the  open- 
ing, with  an  opening  which  may  be  closed  by  a  cork.  It  is  some- 
times practicable  to  open  the  passage  from  the  cavity  of  the  antrum 
to  the  nasal  fossae '-^  with  a  probe  properly  directed,  3  (Fig.  447). 


CHAPTER    XLIV. 

THE    LARYNX. 

The  organ  of  the  voice  is  situated  at  the  top  of  the  trachea,  below 
the  root  of  the  tongue  and  the  hyoid  bone ;  it  consists  of  a  frame- 
work of  cartilages  connected  by  ligaments,  and  provided  with  ap- 
propriate muscles,  blood-vessels,  and  nerves,  and  lined  with  mucous 
meml)rane;  the  cavity  gradually  narrows  from  its  aperture  downward 
to  the  space  between  the  inferior  edges  of  the  orifices  of  the  laryn- 
geal ventricles;  the  narrowest  portion  of  this  space  is  the  glottis,  below 
which  the  cavity  gradually  widens  and  assumes  the  circular  form. ^ 

Its  interior  is  divided  into  two  cavities,  an  upper  and  a  lower,  which  are  sep- 
arated by  two  horizontal  lateral  projections  constituting^  the  glottis,  and  which 
communicate  by  a  cleft-like  space  between  these  projections,  the  rima  glottidis.^ 

1  B.  C.  Brodie.  2  g.  J.  A.  Salter.  3  J.  Leidy.  4  l.  Eisberg. 


THE  LARYNX. 


471 


Before  using  the  lan-ngeal  mirror,  fo  prevent  deposits  of  moisture,  warm  it 
over  a  flame,  as  the  immersion  in  hot  water,  recommended  by  some,  favors  the 
decomposition  of  tiie  silver  coaling  of  the  glass. 

1.  Examinatiou    of   the   larynx   is   made  with   the  mirror  (Fig. 
453).      It    may   l)e    made 
in  the  open  air,  betore  a 
window,  or  in  front  of  a 

lamp    or   other    artilieial  — = 

light,"  thus:  Sit  in  front  of  Fig.  45.3.1 

the  patient  at  snch  a  distance  as  fo  obtain  distinct  and  clear  visions 
of  the  soft  palate  and  wall  of  the  pharynx;  to  explore  the  pharynx, 

direct  the  head  to  be  slightly  bent 
forwards  (Fig.  454),  so  that  the 
lower  border  of  the  upper  incisor 
teeth  shall  be  on  a  plane  horizontal 
with  the  base  of  the  soft  palate,  the 
mouth  widely  distended,  the  tongue 
thrust  forwards  towards  the  chin, 
and  held  by  the  patient  with  a  nap- 
kin; take  the  stem  of  the  mirror  as 
in  handling  a  pen,  and  during  a  deep 

n  inspiration,   pass   the   mirror,    warmed,  well   above 

the  tontrue,  directly  l)ackwards,  until  it  reaches  the 
^\  I  I  uvula ;  now  Hex  the  wrist  and  place  the  mirror  with 
the  lower  border  in  front  of  the  posterior  wall  of 
the  pharynx  ;  the  uvula  and  soft  palate  are  pushed 
b.ackwards  and  somewhat  upwards;  the 
stem  of  the  mirror  is  horizontal,  and  the 
reflecting  surface  looking  obliquely  down- 
wards and  backwards.^  To  explore  the 
interior  of  the  larynx,  simply  incline  the 
head  backwards  (Fig.  455). 

If  artificial  light  is  used  with  a  reflector 
(Fig.  456),  the  lamp,  the  mouth  of  the  patient, 
and  the  eyes  of  the  observer,  should  be  as 
nearly  as  possible  in  the  same  plane;  the  re- 
flector should  be  arranged  so  as  to  tlirow  tlie 
liillit  iuto  the  open  mouth  of  the  patient  and 
illuminate  the  middle  of  the  soft  palate,  the 
uvula,  and  posterior  |iliaryngcal  wall ;  and  then 
the  mirror  may  be  introduced. 3  The  pharynx 
and  larynx  are  brought  into  suitable  position 
for  examination  when  the  patient  pronoiniccs 
ai,  as  \n /(iii\  for  the  larynx  rises,  the  velum  and  uvula  are  lifted,  and  the 
tongue  is  depressed. i    In  this  instrument  the  light  is  reflected  from  the  mirror, 

1  Tiemaun  &  Co.  -  J.  S.  Cohen.  *  A.  E.  Durham. 


Fig.  454. 


472 


OPERATIVE  SURGERY. 


c,  to  the  small  mirror  held  at  the  posterior  part  of  the  mouth,  the  uvula  resting 
upon  its  back. 

The  individual  parts  revealed  by  the  larA'ngoscope,  which  are  otherwise  com- 
pletely invisible  or  rarely  or  never  seen  without  difficult}',  are:  the  postero-in- 
ferior  portion  of  the  base  of  the  tongue;  the  posterior  wail  of  the  pharj'nx  down 
to  its  attachment  to  the  cricoid  and  arytenoid  cartilages;  the  upper  cavity  of 

the  larynx  with  all  its  ana^ 
Ml  tomical  relations  and  con- 

tents; a  portion  of  the  lower 
cavity  of  the  larynx,  par- 
ticularly its  anterior  wall; 
the  anterior  wall,  and  some- 
times lateral  walls  of  the 
trachea  for  a  considerable 
distance,  and  under  favor- 
able circumstances,  down  to 
the  bifurcation,  and  in  a 
few  instances,  even  through- 
out the  whole  length  of  the 
right  bronchus."^ 

2.  Medication  may 
be  with  solid  substan- 
ces, powders,  liquids,  or  vapors.  The  solids  are  most  readily  applied 
by  means  of  a  moderately  thick  aluminum  or  silver  wire,  mounted 
in   a  slender  handle,  and  hollowed  into  a  tiny  cup   (Fig.  457),  or 


Fig.  456. 


Fig.  458.3 


Fig.  457.3 
roughened  at  the  extremity,  which  may  be  dipped  into  va- 
rious substances,  as  nitrate  of  silver,  or  chloride  of  zinc  while 
in  a  state  of  fusion;  the  wire  may  be  easily  bent  at  any  requisite 
angle,  and  there  is  no  danger  of  any  considerable  portion  breaking 
offf  An 
ingenious 
concealed  ^-' 
caustic 

holder  (Fig.  458)  may  be  used,  which,  by  retraction  of  the 
tube,  uncovers  the  caustic  at  the  point  of  application.  Pow- 
ders may  be  applied  with  a  brush  (Fig.  459)  or  by  means  of  the  in- 
sufflator ^  (Fig.  460).  Liquids  may  be  applied  by  means  of  a 
sponge  on  a  properly  curved  Avhalebone  stem  ^  (Fig.  462),  or  injected 
by  means  of  the  laryngeal  syringe^  (Fig.  463).  In  the  form  of 
vapor  produced  by  the  atomizer,  medications  of  the  larynx,  together 
with  the  other  passages,  can  be  effectually  made;  the  atomizer  best 
adapted  for  general  use  is  the  following:  — 

1  B.  Fraenkel.  2  L.  Elsberg.  3  Q.  Tiemann  &  Co.  *  Granger. 

6  A.  E.  Durham. 


THE  LARYNX. 


473 


I'IG.  459.1 


It  consists  of  the  spliere-shaped  brass  boiler  a  (Fig.  461),  steam  outlet  tube  b, 
with  paikiug-bo.x  c,  formed  to  receive  rubber  packing,  through  which  the  atom- 
izing tube  1)  passes,  steam-tight, 
and  by  means  of  wliiiii  tubes  of 
various  sizes  may  be  tightly  held 
against    any    force    of    steam    by 

screwing  down  its  cover  while  the  packing  is  warm;  the  safety- 
valve  E,  capable  of  graduation   for  high  or  low  pressure  by  the 

spring  and  screw  in  its 
fi)|),   the  non-conducting 
handle  f,  by  which   the 
Tig.  4G0.  boiler  may  be  lifted  while 

lu)t,  the  medicament-Clip  and  cup- 
holder  G.  the  support  n,  base  i  i,  the  glass  face-shield  j,  with  oval  mouth-piece 
connected  by  the  elastic  band  k  with  the  cradle  l,  whose  slotted  staff  passes 
into  a  slot  in  the  shield-stand  m  m, 
where  it  may  be  fixed  at  any  height  "—--—, 
or  angle  required  by  the  mill  screw  ;V  ;, 
N.  The  shield-stand  is  formed  into 
a  handle  just  above  the  waste-cup  o,  and 
its  base  is  formed  to  receive  and  hold  this 
cup;  it  has  also  a  sliding  arrangement  and 
set-screw,  by  which  it  may  be  fixed  any 
desired  distance  from  the  atomizing  tubes. 
The  boiler  is  sup|ilied  with  water  through 
the  funnel-shaped  orilice  into  which  the 
safety-valve   is   screwed. 

The  following  formula}  2  fQp  (jjg  prepa- 
ration of  medicated  solutions  are  useful. 
The  amount  of  water  is  one  ounce  in  each 
case,  unless  otherwise  mentioned:  Opium,  extract,  one  fourth  of  a  grain  to  a 
grain;  tincture,  two  to  twenty  drops;  camphorated  tincture,  half  a  drachm  to 
four  drachms;  acetate,  muriate,  and  sulphate  of  morphia,  one  forty-eighth  to 
one  eiglitli  of  a  giain.  Ghxerin,  a  few  drachms  to  an  ounce,  undiluted,  or  di- 
luted witii  from  one  to  ten  parts  of  water.  Tal)le  salt,  one  to  twenty  grains. 
Chlorate  of  potassium,  one  to  fifteen  grains.  Permanganate  of  potassium,  one 
half  to  five  grains.  Iron,  tr.  chloride,  one  to  thirty  minims;  sulphate  half  a 
grain  to  ten  grains.  Alum,  one  to  twenty-four  grains.  Sulphurous  acid,  ten 
to  forty  minims,  undiluted,  or  diluted  with  from  one  to  ten  parts.  Tannic  acid, 
one  to  sixteen  grains.  Sulphate  of  zinc,  half  a  grain  to  ten  grains  to  the  ounce 
of  water.  Sulphate  of  copper,  one  to  twenty  grains.  Tr.  iodine,  one  to  twenty 
drops.  Acetate  of  lead,  one  to  ten  grains.  Oil  of  turpentine,  one  to  five 
drops.  Chloride  of  zinc,  one  tenth  of  a  grain  to  two  grains.  Carbolic  acid- 
one  to  two  grains  of  the  crystalized  acid:  carbolic  acid  water,  five  to  ten  drops. 
Infusion  of  tar,  one  to  four  drachms.  Nitrate  of  silver,  one  sixth  of  a  grain 
to  ten  grains.  Corrosive  chloride  of  mercury,  one  twelfth  of  a  grain  to  two 
grains. 

3.  Wounds  penotratins  tlie  larynx,  such  as  arc  inflicted  by  suicides, 
thou;j;h  not  usually  attended  by  much  h:cniorrha<re,  are,  as  a  rule, 
very  dauL'erous,  owin<:  to  the  after  complications  liable  to  occur,  as 

1  G.  Tiemann  iSc  Co.  ^  j.  g.  Cohen.  8  Codman  &  Shurtleff. 


474 


OPERA  TIVE  S  UR  GER  Y. 


inflammation    and  cedema  about  the  glottis,  or  in  the  trachea  and 
bronclii,  thickening  of  tlie  mucous  membrane  around  the  wound,  or 

the  contraction  of  the  cic- 
atrices; punctured  wounds, 
penetrating  between  the  vo- 
cal cords,  or  injuring  one 
or  both,  cause  oedema  about 
the  glottis  and  suffocation; 
these  wounds  do  not  gape 
much,  unless  the  cartilage  is 
Fig.  462.1  entirely  divided,  and  hence 

the  free  escape  of  air,  blood,  mucus,  and  pus,  is  hindered,  and  there 
is  a  liability  to  emphysema,  and  the  entrance  of  matters  into  the  air- 


FiG.  4G3.1 


passages.  First,  promptly  arrest  the  haemorrhage,  if  venous,  by  con- 
tinued pressure;  if  arterial,  by  ligature  or  torsion  of  every  bleeding 
artery;  in  emergencies  it  may  be  necessary  to  remove  clots  instantly 
from  the  mouth  or  pharynx,  or  suck  blood  from  the  trachea,  or  resort 
to  artificial  respiration ;  remove  any  portion  of  the  epiglottis  which 
may  be  loose,  and  if  the  tongue  is  divided  and  impedes  respiration, 
prevent  retraction  l)y  means  of  a  ligature  passeil  through  its  tip;  when 
all  bleeding  is  arrested,  and  there  is  no  immediate  hindrance  to  res- 
piration, approximate  the  cut  surfaces  by  placing  the  patient  in  bed, 
with  the  shoulders  raised,  the  neck  and  head  flexed,  and  the  head 
fixed  by  bandages  attacheil  to  each  side  of  a  firm  night-cap  and  fast- 
ened to  a  roller  applied  around  the  chest;  neither  sutures  nor  adhesive 
plasters  are  I'equired,  unless  the  cartilages  are  cut  in  several  phices, 
and  are  much  separated  from  each  other,  when  one  or  more  sutures 
mny  be  passed  through  the  cellular  tissue  surrounding  them.  The 
patient  should  remain  in  a  moist  and  warm  atmosphere,  and  the  res- 
piration be  carefully  watched  ;  if  it  become  obstructed,  or  emphysema 
appear,  remove  the  sutures,  if  present,  and  search  for  the  cause;  if 
suffocation  impends,  enlarge  the  wound  and  introduce  a  tracheotomy 
canula,  or  make  a  fresh  opening  below  and  insert  the  canula;  if 
constriction  occur  from  cicatrization,  tracheotomy  may  be  i-equired, 
after  which  dilatation  may  be  effected  with  bougies;  if  fistulas  remain 
and  respiration  is  not  impeded  by  the  closure  of  the  fistulse,  pare  the 
edges  and  unite  them,  or  transplant  skin.^ 

4.  Fractures  of  the  cartilages  ^  are  of  extreme  danger,  owing  to 
1  G.  Tiemann  &  Co.  "  A.  E.  Durham. 


THE  LARYNX.  475 

the  A-arious  obstructions  to  rt'spiration  to  whioh  they  may  give  rise  by 
the  (lis])laceiiu'iit  of  the  fractured  portions,  tlie  spasm  of  the  glottis, 
the  entrance  of  blooil  into  tlie  air-p:issage,  the  local  or  general  emphy- 
sema, or  l)y  infiainmation  or  (Eiiema  of  tlie  mucous  membrane;  there 
is  usually  flattening  of  the  fteck,  ecchymosis  and  emphysema,  when 
the  mucous  membrane  is  lacerateil  ;  the  patient  generally  suffers 
great  pain,  aggravated  by  pressure  and  attempts  at  swallowing  or 
speaking,  with  lividity,  small  pulse,  convulsive  cough,  hoarseness, 
or  aphonia;  there  is  mobility  of  the  fragments,  and  often  crepitus 
is  detected;  but  it  must  not  be  mistaken  for  the  roughness  elicited  on 
moving  the  larynx  of  old  people  on  the  cervical  spine. ^  The  treat- 
ment of  simple  fracture,  without  dyspnoea,  may  be  limited  to  exter- 
nal support  of  the  parts  with  adhesive  plaster;  but  when  there  is 
continued  dys[)n(ea  from  the  first,  or  bloo<ly  expectoration,  or  if  suf- 
focation becomes  imminent  at  any  period,  perform  tracheotomy  with- 
out delay  and  adjust  the  displaced  parts;  retain  them  in  position  by 
suture,  or  an  interlaryngeal  splint  consisting  of  an  inllated  rubber 
ring.2 

5.  Foreign  bodies  entering  the  larynx  are  arrested  in  its  in- 
terior, or  desceml,  according  to  their  size,  form,  and  weight ;  when 
arrested  in  the  larynx,  they  may  lodge  in  one  of  the  ventricles  or  be- 
come fixed  between  the  vocal  chords;  occasionally  they  are  arrested 
at  the  junction  of  the  larynx  and  trachea;  the  first  symptoms  of  the 
entrance  of  the  body  into  the  air-passages  are  usually  severe  and 
characteristic;  the  patient  gasps  for  breath,  coughs  violently,  the 
face  becomes  livid,  the  eyes  protrude,  the  body  is  contorted,  and  he 
is  like  one  choked  by  the  hand;  if  the  body  is  lodged  in  the  larynx, 
the  symptoms  will  vary  with  its  size  and  peculiarities  ;  it  may  be  so 
large  as  to  prove  fatal  by  suffocation,  or  so  small,  hard,  and  smooth 
as  to  cause  but  slight  symptoms.  Ordinarily  there  is  aphonia,  with 
pain  and  soreness,  and  uneasiness  in  that  region  ensues,  with  «lysp- 
ncea  and  whistling  sound  in  respiration;  at  the  same  time  there  is 
absence  of  tracheal  and  bronchial  disturbance.*  The  diagnosis  is 
made  positive  when  the  symptoms  permit  an  examination  with  the 
laryngoscope.  In  the  treatment,  as  a  general  rule,  the  trachea 
shoidd  be  opened  with  as  little  delay  as  possible  in  every  case  in 
which  a  foreign  botly  is  certaiidy  known  to  be  retained  in  any  part 
of  the  air-passages,  for  by  this  means  the  immediate  safety  of  the 
patient  is  secured,  and  sulxeqnent  expulsion  or  removal  aided.  An 
antesthetic  should  always  be  given  when  the  symptoms  admit  of  de- 
lay, but  in  many  cases  there  is  not  a  moment  to  lose,  and  the  trachea 
must  be  opened  at  once;  even  if  the  patient  cease  to  In-eatlie  before 
this  is  accomplished,  the  operation  should  be  completed,  and  arti- 
1  F.  Le  G.  Clark.  2  L.  Elsberg.  8  s.  D.  Gross. 


476 


OPERATIVE  SURGERY. 


Fig.  464. 


ficial  respiration  instituted  and  perseveringly  maintained.  In  those 
cases  where  the  symptoms  are  so  shght  as  to  cause  hesitation  before 
adopting  such  severe  treatment,  delay  is  dangerous, 
for  an  interval  of  calm  constantly  precedes  the  recur- 
rence of  urgent  symptoms,  and  temporary  freedom 
iwan  distress,  instead  of  contra-indicating  the  opera- 
tion, affords  the  best  opportunity  for  its  performance.^ 
In  deciding  as  to  the  particular  form  of  ojjcration  in 
any  ca?^e,  it  must  be  borne  in  mind  that  while  laryn- 
gotomy  is  simple,  easy,  and  free  from  risk,  it  is  not  as 
a])i)licable  to  early  childhood  as  tracheotomy,  on  ac- 
count of  the  very  limited  dimensions  of  the  crico- 
thyroid spat'C.  Jn  the  operation  of  laryngotomy,  the 
structures  to  be  divided  are  the  skin,  cervical  fas- 
ciae and  the  crico-thyroid  membrane  (Fig.  464).  Place  the  patient 
on  a  table  with  the  head   and  shoulders  jn-operly  elevated  and  firmly 

fixed  (Fig.  465);    make  an 
incision  with  a  narrow  scal- 
pel   (Fig.    466)    along    the 
centre  of  the  larynx,  from 
the  top  of   the   thyroid   to 
the  base  of  the  cricoid  car- 
tilage;  this  incision  will  be 
fully  one  and   a  half   inches;   if  the  crico-thyroid 
artery  bleed,  it   must   be   twisted  or  tied;   divide 
the  crico-thyroid  membrane  in  the  same  direction 
in   its   whole   extent;    if  the  opening  is  not   suffi- 
ciently large,  prolonir  the  incision  into  the  contigu- 
ous cartilages,  or  transversely.^ 

If  expulsion  should  not  imme- 
diately take  place,  introduce  the 
double  canula  (Fig.  467),  which  secures  freedom  of  respiration  and 
stops  haemorrhage  ;  the  contracted  muscles  of  the  larynx  may  be- 
come relaxed,  and  the  foreign  body,  set  at  liberty, 
be  expelled.  When  the  patient  has  recovered 
from  the  immediate  effect*  "f  the 
c.inida  may  be  re- 
moved, and  the  lar- 
Fiu.  407.  ynx    explored    by 

means  of  a  probe  ;  if  the  body  is  not 
detected,  use  a  larger  instrument,  as 
an  elastic  catheter;   the   laryngoscope 

may  also  be   used,   and  if  the  foreign  body  is  detected   it 
1  A.  E.  Durham.  ^  S.  D.  Gross. 


I'iG.  4WJ. 


th 


lay  be 


THE  LARYXX. 


477 


extraote<l  with  curved  forceps  (Fi<r.  AC,)*,).  If  not  extracted,  the 
patient  may  now  be  safely  inverted  and  the  bacic  struck  repeateil 
blows,  which  often  dislodges  smooth,  rounded  bodies,  as  shut,  bullets, 
or  pieces  of  money  ;  if  these  means  all  fail,  the  larynx  must  be  fully 
exposed.* 

Tliyrotomy,  incision  of  the  thyroi<l  cartilage,  is  not  a  diniriilt  op- 
eration, and  does  not  involve  much  ri>k.  Place  the  patient  in  the 
position  alri'ady  given  (Fig.  46.j)  ;  make  the  incision  through  the 
cartilage  perpendicularly  upwards  from  the  opening  in  the  crico- 
thyroid membrane  previously  made,  and  exactly  in  the  middle  line. 
Make  the  same  search  as  before,  and  when  the  foreign  body  is  re- 
moved bring  the  edges  of  the  incision  through  the  thyroid  body  to- 
gether, and  secure  them  by  suture  ;  the  laryngeal  tube  may  be 
retained  a  few  days,  until  all  indications  of  local  mischief  have 
passed  away.* 

6.  QJdema  of  the  larynx  is  a  serous  infiltration  of  the  submucous 
connective  tissue  of  the  upper  portions  of  the  lar- 
ynx ;   the  most  frecjuent  seat  is  in  the  aryteno- 
epiglottidean  folds,  but  it  may  also  involve   the 
epiglottis,  or  involve  the  lips  of  the  glottis,  con- 
verting them  into  thick  obstructing  pads  ;  it  may  occur  in 
acute  laryngitis,  after  the  inhalation  of  hot  vapors,  or  the 
deglutition  of   hot  licjuids,  or  suddenly,   in  the  course  of 
other  diseases;  but  generally  the  immediate  exciting  cause 
is   exposure   to   cold   and    moisture ;    the    symptoms   are 
marked,  and  in  most  cases  come  on  more  or  less  suddenly, 
and  increase  in  severity  with  great  rapidity;    there  is  a 
sense  of  constriction  in  the  throat,  difficulty  of  inspiration, 
with  a  stridulous  sound,  feebleness  or  hoarseness  of  voice, 
dysphagia,  and  the  phenomena  of  impending  suffocatioi\; 
inspection  usually  reveals  inflammation  and  intiltration  of 
the  structures,  but  often  no  evidence  of  the  disease  is  ap- 
parent;   exploration   with  the   finger  detects   the   swollen 
tissues  about  the  epiglottis;   the  laryngoscope  reveals  the  -^,7 laai 
exact   location  and    extent   of   the   effusion.      The   treat- 
ment is  prompt  incisions  into  the  oedematous  tissues.     Scarification 
may  be  performed  with  a  curved  instrument 
(Fig.  4G!i)3  having  cutting  edges,  or  a   ring 
(Fig.  470)'*  with  a  cutting  point  may  be  used 
on  the  end  of  the  right  index.     If  these  in- 
struments are  not  at  hand,  use  a  curved  hernia 
knife,  or  a  curved  blunt-pointed  bistoury,  the 
blade  being  wrapped  with  cloth  to  witliin  an  inch  of  the  point.    Pass 
1  A.  E.  Durham.  2  g.  Tiemaiin  &  Co.  3  q.  Biuk.  ••  Grant. 


Fig.  470. 


478  OPERATIVE  SURGERY. 

the  index  finger  of  the  left  hand  backward  over  the  tongue  to  the 
epiglottis;  along  the  finger  as  a  guide,  pass  tlie  knife,  the  edge  for- 
ward, to  the  posterior  part  of  the  epiglottis,  and  incise  the  mucous 
membrane  in  several  places.  The  tumid  folds  of  membrane  are 
readily  felt  by  the  index  finger,  -which  serves  as  a  guide  to  the  knife. 
It  is  a  very  simple  operation,  and  gives  instant  relief  to  the  most 
urgent  symptoms ;  it  should  be  performed  even  after  respiration 
seems  to  have  been  suspended.-^ 

7.  Bvirus  and  scalds  -  result  from  inhalation  of  flames,  hot  va- 
pors, and  attempts  to  swallow  boiling  liquids  ;  violent  inflammation 
follows,  with  great  pain  in  attempting  to  swallow,  hoarseness,  dysp- 
ncEa,  and  croupy  symptoms,  which  gradually  become  extreme;  in  a 
fair  proportion  of  cases  little  other  treatment  is  required  than  a  warm 
bed,  the  api)lication  of  a  hot  sponge  to  the  larynx,  and  the  inhalation 
of  warm,  moist  air;  in  more  severe  cases,  blisters  or  leeches  are  use- 
ful; but  if  the  symptoms  rapidly  progress  and  laryngeal  spasm  occurs, 
tracheotomy  must  be  promptly  performed,  chloroform  being  given 
without  fear. 3 

8.  Non-malignant  growths,  polypi,  in  the  larynx,  may  be  papil- 
lomatous, fibrous,  sarcomatous,  adenomatous,  cystic,  cartilaginous, 
and  osseous.  The  papillomata  are  far  the  most  frequent;  they  ap- 
pear as  warty  elevations  from  the  mucous  membrane,  usually  of 
the  anterior  part  of  the  larynx,  near  the  insertion  of  the  true  vocal 
chords,  or  from  the  boundaries  of  the  ventricles,  and  in  some  cases 
from  the  true  vocal  chords  ;  they  are  generally  multiple,  and  sooner 
or  later  more  or  less  completely  coalesce.  The  fibrous  growths  usually 
spring  from  the  true  vocal  chords  or  adjacent  parts,  are  smooth 
and  globular,  may  be  sessile  or  pedunculated,  and  do  not  gener- 
ally exceed  the  size  of  a  pea.  The  adenomatous  growth  arises  from 
the  mucous  membrane  supplied  with  glands,  as  the  arytenoid  car- 
tilages or  folds,  or  the  base  of  the  epiglottis ;  when  sessile,  they 
appear  lobulated;  and  when  pedunculated,  pyriform.  Cystic  tu- 
mors are  rare,  and  may  appear  in  almost  any  part  of  the  larynx; 
cartilaginous  and  osseous  growths  have  been  recorded;  mixed  tu- 
mors may  occur,  in  which  the  fibrous,  fibro-cellular,  and  glandular 
elements  vary  in  relative  proportion.  The  condylomata  of  syph- 
ilis, the  thickened  elevations  of  phthisis,  and  the  protuberances 
of  localized  chronic  inflammation,  can  scarcely  be  distinguished  in 
some  cases  from  new  growths.  The  symptoms  are,  in  varying  de- 
grees of  severity,  difficulty  of  breathing,  alteration  or  extinction 
of  voice,  and  cough;  but  the  diagnosis  is  most  certainly  made  with 
the  laryngoscope,  or  by  digital  exploration,  especially  in  children. 
The  treatment  should  be  directed  to  the  removal  or  destruction  of 

1  L.  Kavenbill.  2  A.  E.  Durham.  2  T.  Bryant. 


THE  LARYNX. 


479 


all  non-mali5;nant  new  growths  as  soon  as  practicable  ;  in  some 
cases  it  is  absoliiU-ly  necessary,  and  in  others  it  may  he  desirable  to 
perform   traclROtomy  before    proceeding    to   any    further  o])erative 

measures.     This  question  must 

be  determined  by  the  urgency 
of  the  symptoms,  and  the  dilli- 
cuities  and  dangers  of  the  op- 
eration about  to  be  undertaken. 
The    methods    of    removal    arc 
estimated    thus:     (1.)   Caustics 
are   useful   in    small    papillary 
growths;  use  the  laryngoscope, 
and    apply    it   with    a    properly   curved    caustic-h( 
(2.)  Forceps  should  be  employeil  to  remove  small,  fibrou 
fibroid,  fibro-cellular,  and  papillary  growths;  the  force 
may  be  of  various  forms.     (3.)  The  wire  snare  eniplo3ed 
is  applicable  to  cases  in  which  the  growths  are  soft  atid 
project  so  that  they  may  be  easily  caught ;  the  instriunent 
should  be  properly  curved  anil  carry  a  wire  luop.^    (4.)  The 


Fig.  471. 


Fig.  472. 

caustic  is  suited  to  single  fibrous  tumors  with  peduncles  too  strong  to 
allow  of  their  safe  removal  with  forceps;  it  consists  in  encircling 
i-.::.:~v,  the  growth  with   a   platinum    wire,    which 

*"• -vX  :■..  can  be  intensely  heated  by  a  galvanic  bat- 
''\%  tery.2  (5.)  ThJ  knife  (Fig.  471)  8  and  scis- 
sors (Figs.  472, 
473)^  may  be 
used  for  the  sep- 
aration of  firmly 
attached  growths 
[>/  This  instrument  can  be  un-     which  cannot  be 

i.<:  jointed,  and  a  knife,  scissors,      p„lled  off  by  the 

■■■:■•'  or     forceps     attaclied.    and      ,  ^^  ,. 

worked  with  the  .'^ame  lever.       lorceps.       (^0.; 
Fig.  473.6  Puncture  is   re- 

quired, in  the  treatment  of  cysts,  by  a  curved  and  guarded  bistoury 
(Fi'^.  4  74).''     (7.)   Thyrotomy  is  the  most  certain  and  safest  method 

1  G.Johnson.     -  Tiirck ;  Bruns.    ^  Tobold.    *  H.Smith.    *  Bruns;  Matbieu. 
8  G.  Tieniaun  &  Co.  '  Buck;  Mackenzie. 


480 


OPERATIVE  SURGERY. 


when  the  growths  are  numerous  or  very  large,  or  single  but  firmly- 
attached,  and  when  the  patient  is  young  and  ill  able  to  bear  the 
introduction  of  instruments  through  the  narrow  natural  passages. 
The  operation  may  be  performed  at  once  ^  wliere  the  growth  is  small, 
or,  if  large,  when  the  removal  could  be  effected  by  a  slight  amount  of 
injury  to  intra-laryngeal  structures ;  but  if  a  great  amount  of  injury 
is  antici[)ated,  it  would  be  safer  to  facilitate  respiration  by  perform- 
ing tracheotomy  in  advance. ^ 


9.  Malignant  growths  are  commonly  of  the  epithelio- 
matous  variety ;  they  generally  commence  on  the  pharyn- 
geal aspect  of  the  nuicous  membrane  covering  the  aryte- 
noid or  ci'icoid  cartilages  ;  there  is  irregular  thickening, 
the  surface  is  grayish,  and  the  edges  are  elevated.^     The 

Fig.  474.     treatment  is  extirpation,*  a  not  difficult  operation,  which 

gives  60  per  cent,  of  recoveries. 

The  only  special  instrument  required  is  the  tanipon-canu]a,5  which  sonsists  of 
jin  ordinary  traclieal  canula,  over  the  vertical  part  of  wliich 
a  ring-shaped  rubber  balloon  is  drawn;  by  means  of  a  rub- 
ber tubinj^  connected  with  it,  provided  with  a  stop  cock, 
this  contrivance  can  be  inflated  with  the  effect  of  surround- 


FiG.  475.6 


mg  the  canula  with  a  thick  roll  and  obliterating  the  space  between  the  canula 
and  tlie  trachea.  Before  the  operation,  tracheotomy  is  performed,  the  canula  in- 
serted into  the  trachea,  and  the  rubber  dilated,  thus  preventing  the  escape  of 
blood  into  the  lungs.  The  rest  of  the  apparatus  consists  of  a  tracheal  tube  with 
a  moval)Ie  flange,  a,  an  ether  inhaler,  c,  covered  with  flannel,  attached  by  a  rub- 
ber tube  to  the  tracheal  portion  at  «;  a  bag  connected  at  b,  by  a  tube,  with  stop- 


1  E.  Cutter.  2  j.  g.  Cohen. 

6  F.  Trendelenburg. 


3  A.  E.  Duvluun. 
6  G.  Tieniann  &  Co. 


•1  T.  Billroth. 


THE  LARYNX.  481 

cock,  to  the  rubber  dilator,  on  the  tracheal  tube,  for  the  purpose  of  expanding 

the  rubber  bag  on  tlic  tracheal  tube,  and  thus  preventing  the  entrance  of  blood 
to  the  trachea.  This  instrument  lias  recently  been  slightly  nioililied  i  (I'ig.  475) 
as  follows:  The  tracheal  tube  is  reduced  in  length,  as  also  the  rubber  air  dilator, 
at  the  extremity  of  the  tube,  which  now  forms  a  globular  shape  when  inflated. 

Tlie  stops  of  tlic  operation  '^  iiiiist  be  determined  in  eaeli  case  by  the 
nature  of  the  disease;  the  simplest  plan  is  as  follows:  a  single  ver- 
tical median  incision  from  the  liyoid  bone  to  the  second  ring  of  the 
trachea,  exposing  tlie  front  of  the  laryn.x;  the  two  sides  of  the  car- 
tilaginous box  are  then  freed  from  the  musck'S  quite  back  to  the  gul- 
let; up  to  this  point  the  larynx  is  not  opened,  and  no  blood  can 
escape  into  it ;  the  larynx  is  then  sei)arated  from  the  trachea  by  a 
transverse  cut,  the  trachea  having  been  previously  transfixed  and 
helil  forwards  with  a  sharp  hook  ;  a  large  syphon  tube  of  vulcanite, 
fitting  the  trachea,  is  put  in,  to  keep  out  the  blood  and  permit  free 
respiration ;  if  this  is  neatly  and  carefully  done,  there  is  no  need  of 
preliminary  tracheotomy  and  use  of  a  tampon,  which  has  the  disad- 
vantage of  largely  increasing  the  length  of  the  wound.  If  there  is 
much  oozing  of  blood,  something  may  be  gained  by  lowering  the 
head  of  the  patient  so  that  the  tlow  of  blood  is  in  the  direction  away 
from  the  trachea;  the  upper  and  posterior  attachments  of  the  larynx 
are  next  cut,  care  being  taken,  in  separating  the  gidlet  and  pharynx, 
to  keep  the  edge  of  the  knife  close  to  the  cartilages,  so  as  to  avoid 
button-holing  the  gidlet;  it  might  be  well  to  mop  the  raw  surface  out 
with  solution  of  chloride  of  zinc,  thirty  grains  to  the  ounce,  at  the 
close  of  the  operation;  but  it  is  not  advisable  to  irrigate  the  wound 
in  any  way  afterwards,  on  account  of  the  gulping  and  irritation 
which  it  sets  up.  ]\Iuch  may  be  done  by  keeping  the  air  of  the  room 
pure  and  disinfected.  The  tracheal  tubes  should  be  as  large  as  the 
trachea  will  admit,  and  those  made  of  hard,  polished  vulcanite  are 
best.  When  oiled  inside  and  outside  with  earbolized  oil,  they  are 
easily  changed,  and  remain  clean  for  a  considerable  time.  The 
after-treatment  requires  careful  attention  to  the  tube,  to  avoid  any 
disturbance  of  the  respiration,  protection  of  the  lungs  from  cold  or 
changes  liable  to  cause  pneumonia,  a  uniform  temperature  of  70^  F. 
and  earbolized  air,  and  nourishing  diet.  Recovery  has  usually  been 
rapid. 

The  last  feature  in  the  treatment  is  the  introduction  of  an  artificial  vocal  ap- 
paratus.''^  This  must  be  delayed  until  the  wound  is  fairly  healed  and  contracted, 
before  which  time  the  apparatus  is  useless  from  its  small  size.  This  ap])aratus 
consists  of  two  tubes,  one  of  which  passes  into  the  open  trachea,  while  the  oilier, 
fitting  into  the  tube,  passes  upwards  to  the  epiglottis.  Into  the  upper  tube  slides 
a  silver  case  containing  a  plate  with  a  vibrating  reed.     The  anterior  opening  of 

1  G.  A.  Peters.  2  D.  Foulis.  3  Gussnbauer. 

31 


482  OPERATIVE  SURGERY. 

the  apparatus  is  closed  bj'  a  button,  and  the  current  of  air  is  directed  past  the 
reed,  and  through  the  aperture  in  the  tubes.  As  the  upward  current  impinges 
on  the  reed,  the  latter  is  thrown  into  vibrations,  and  a  continuous  musical  note 
is  produced,  which  is  then  modulated  into  vowels  and  consonants  by  the  month. 
This  instrument  has  been  greatly  improved  in  the  power  of  vocalization  by 
means  of  reeds  made  of  better  metals. i  It  is  stated  that  the  articulation  of  the 
patient  with  this  apparatus  is  wonderful;  except  for  the  monotonj',  it  cannot  be 
distinguished  from  the  natural  voice;  the  vowels  are  perfectly  clear  and  distinct, 
both  in  whispering  with  the  reed  out  and  in  intoning  with  the  reed  in  the  tube.2 

E.xtirpation  of  larynx,  hyoid  bone,  portion  of  tongue,  pharynx, 
and  oesophagus,  may  be  successfully  performed  as  follows  i^  — 

The  patient  being  properly  placed  and  under  an  anaesthetic,  open  the  trachea 
and  introduce  the  tampon-canula  through  which  anaesthesia  is  maintained; 
make  a  transverse  incision  tlirough  the  skin  four  fifths'  of  an  inch  above  the 
hyoid  bone,  from  the  inner  edge  of  one  sterno-mastoid  muscle  to  the  other; 
from  tlie  centre  of  this  incision  carry  another  in  the  middle  line,  over  the  larynx, 
close  down  to  the  tracheal  opening;  turn  back  the  two  flaps,  expose  the  thyroid 
cartilage,  and  extirpate  all  infiltrated  glands,  whether  lymphatic  or  submaxil- 
lary; divide  the  mylo-hyoid,  digastric,  and  hyo-glossus  muscles,  and  expose  and 
tie  the  lingual  arteries;  now  draw  the  larynx  downwards  and  forwards  by  a 
sharp  hook  fixed  ia  the  hyoid  bone,  and  draw  the  tongue  out  of  the  mouth  by  a 
ligature  passed  through  the  tip;  divide  the  tongue  at  the  proper  place,  tie  the 
superior  thvroid  arteries,  and  cut  through  the  lateral  wall  of  the  pliarynx,  and 
the  pharyngo-palatine  arches;  expose  the  external  carotid  arteries,  drawn  for- 
wards with  tiie  pharj-nx,  tie  them  in  two  places,  and  divide  between  the  liga- 
tures; also,  cut  the  lingual  and  hypoglossal  nerves;  the  larynx  now  remains 
connected  onlv  with  the  trachea,  which  may  be  divided  just  below  the  cricoid 
cartilage;  dress  the  wound  by  first  inserting  a  tracheal  canula,  protecting  the 
oesophagus,  laying  the  flaps  in  apposition  without  sutures,  and  applying  com- 
presses wet  with  salicylic  acid  solutions. 
A  great  variety  of  incisions  may  be  practiced  in  making  extensive  dissections 
to  remove  growths  in  this  region  (Fig.  470).  The  root  of 
the  tongue  may  be  engaged  in  the  chain  of  the  tcraseur 
at  7,  or  the  base  may  be  exposed  by  the  incision  3,  5,  4; 
or  the  base  of  the  tongue,  larynx,  5,  6,  pharynx,  and 
oesophagus  may  be  exposed  by  dissecting  flaps,  .3,  5,  2, 
C*  and  4,  5,  2,  or  the  lip,  chin,  and  inferior  maxilla  may  be 
O  '^  separated,  1,  5,  2,  exposing  the  entire  inside  of  the  mouth. 
I^'^w"^^      ■■  Though  the  removal  of  so  many  important  parts  requires 

3^.     \  an  amount  of  dissection  apparently  destructive  of  condi- 

f  ^  tions  essential  to  life,  yet  experience  has  proved  that  re- 

FiG.  476.  covery  is  often  very  prompt,  and  the  sufferer  has  been 

made  remarkably  comfortable. 

10.  Abscess  forms  in  the  connective  tissue,  around  and  behind  the 
larynx,  and  by  its  pressure  causes  difficult  deglutition,  dyspnoea, 
agLiravated  l)y  horizontal  posture,  low  and  hoarse  cough,  quite  differ- 
ent from  the  clanging,  brassy  cough  of  the  early  stage  of  croup;  the 
treatment  is  evacuation  of  the  pus  as  early  as  possible.'* 

1  Foulds.        ^  D.  Foulis.        3  Von  Langenbeck.        *  Stephenson;  Parry. 


THE   TRACHEA. 


483 


11.  Bursal  tumors,  liyfri'oinata,  oc-ciir  in  the  tliyro-hyoi<l  regions; 
(1)  in  front  of  the  thyroid  cartilage;  (2)  below  the  hyoid  bone;  (3) 
at  the  root  of  tlie  tongue  ;  they  appear  as  eysts,  and  may  increase  in 
size  so  as  to  interfere  witii  the  deglntition,  articulation,  and  res- 
piration; treatment  by  ])uncture  and  injection  of  iodine,  after  dis- 
charge of  the  eysts,  offers  a  better  chance  of  success  than  incision, 
excision,  or  extirpation.^ 


CHAPTER   XLV. 

THE   TRACHEA;    THE   THYROID  BODY;    THE  BROXCHI. 


I.    THE  TRACHEA. 

The  trachea  (Fiir-  477)  extends  from  tlie  lower  border  of  the  cri- 
coid cartilage  of  the  larynx,  on  a  level  with  the  fifth  cervical  verte- 
bra, to  a  point  opposite  the  third  dorsal  ver- 
tebra, where  it  bifurcates  into  the  two  bron- 
chi; it  is  placed  in  the  middle  plane  of  the 
body  and  usually  measures  from  four  to  four 
and  a  half  inches  in  length,  and  from  three 
quarters  to  an  inch  in  breadth,  though  both 
the  length  and  breadth  vary  according  to  the 
position  of  the  larynx  and  the  direction  of 
the  neck;  in  the  neck  and  thorax  it  rests  on 
the  oesophagus.  The  common  carotid  ar- 
teries are  situated  on  either  side;  the  lateral 
lobes  of  the  thyroid  body  embrace  the  upper 
end  and  its  isthmus  crosses  just  below  the 
larynx. - 

1.  Exploration  of  the  trachea  is  effected 
by  the  same  methods  as  that  of  the  larynx. 
2.  Wounds'  which  divide  the  trachea  are  usually  attended  by 
considerable  lijemorrhage,  as  the  superior  and  inferior  thyroid  ar- 
teries, the  thyroid  veins  and  the  superficial  jugulars  are  liable  to 
injury  ;  the  thyroid  body  and  recurrent  laryngeal  nerves  are  some- 
times imi)licated.  If  the  tube  is  partially  divided,  the  edges  of  the 
wound  gape  but  slightly  and  are  easily  kept  in  contact;  but  if  it  is 
completely  divided,  the  ends  se])arate  widely,  the  lower  beintj  drawn 
downwards  at  each  inspiration  under  the  neighboring  parts  and 
thus  inii)eding  resjnration.  In  deep  wounds,  the  oesophagus  rarely 
1  J.  S.  Colien.  2  Quaiu's  Anat.  »  A.  E.  Durham. 


484  OPERATIVE  SURGERY. 

escapes,  and,  when  injured,  materials  swallowed  pass  through  the 
wound.  The  treatment  is,  prompt  suppres.-ion  of  haemorrhage  by 
pressure  of  veins  and  ligation  of  arteries;  approximation  of  the 
wound  by  flexion  of  the  head  on  the  chest,  and,  if  the  oesophagus  is 
wounded,  the  passage  of  a  tube  by  the  mouth  beyond  the  divided 
parts  to  convey  food  to  the  stomach ;  careful  watching  throughout 
to  prevent  suffocation  from  the  entrance  of  blood  or  pus;  and  the 
prevention  of  constriction  by  granulations. 

3.  Obstruction  of  the  larynx  and  trachea  frequently  occurs 
from  the  lodgment  of  foreign  bodies,  or  intlammatory  effusions  Avithin, 
as  in  croup,  or  pressure  from  without,  as  tumors.  Foreign  bodies 
are  not  often  arrested  in  the  trachea,  but  descend  into  the  bronchial 
tubes;  if  arrested,  they  do  not  remain  long,  unless  they  are  sharp 
and  the  end  becomes  implanted  in  its  Avails. ^  If  the  body  is  light, 
of  small  size,  Avith  no  great  irregularity  of  surface,  it  may  constantly 
change  its  position,  creating  paroxysms  of  cough  Avith  li\  idity,  swol- 
len cheeks,  and  protruding  eyes.^  The  diagnosis  depends  upon  the 
history  of  the  case,  the  sudden  onset,  and  peculiarity  of  the  symp- 
toms. Whatever  may  be  the  cause  of  the  obstruction,  there  is  often 
a  necessity  for  immediate  relief  to  the  embarrassed  respiration;  un- 
less the  cause  is  susceptible  of  ])rompt  removal,  the  Avindpipe  must 
be  opened  at  some  point.  Laryiigotomy  should,  as  a  rule,  be  pre- 
ferred in  the  adult,  and  tracheotomy  in  young  children. 

4.  Tracheotomy  may  be  performed  above,  through,  or  below  the 
thyroid  isthmus;  the  latter  {)lace  is  to  be  preferred,  as  it  gives  more 
room  for  the  canula.  If  there  is  immediate  danger  pi'oceed  as  fol- 
lows: the  patient  being  anaesthetized  or  not,  as  may  be  deemed  best, 
and  firmly  held,  the  shoulders  elevated,  and  the  head  extended, 
stand  at  his  right  side  and  place  the  forefinger  of  the  left  hand  on 
the  left  side  of  the  trachea,  and  the  thumb  on  the  right  side,  and 
make  uniform,  steady,  deep  pressure  until  the  pulsation  of  both  ca- 
rotid arteries  is  felt ;  noAV  slightly  approximate  the  finger  and  thumb 
until  the  trachea  is  firmly  and  securely  held  between  them,  and  main- 
tain this  grasp  until  by  repeated  cuts  in  the  median  line  the  trachea 
is  exposed  ;  the  forefinger  of  the  right  hand  should  be  used  from 
time  to  time  to  determine  the  relation  of  parts;  Avhen  the  trachea  is 
exposed  it  may  be  opened  at  once,  or  seized  by  a  sharp  hook  and 
held  Avhile  it  is  opened;  make  the  opening  by  thrusting  the  point  of 
the  knife  (Fig.  465),  the  edge  directed  upAvards,  into  the  tube,  and 
carrying  it  upAvards  to  a  sufficient  extent.^ 

It  is  important  to  keep  strictly  in  the  median  line,  otherwise  the  canula  will 
stand  awry  in  the  Avound,  and  its  extremity  Avill  be  turned  sharply  against  the 
membrane  of  the  trachea,  and  Avill  not  only  cause  irritation,  but  will  quickly 
1  S.  D.  Gross.  2  A.  E.  Durliam. 


THE   TRACHEA. 


485 


become  blocked  with  mucus. i  The  point  of  tlie  ktiife  must  certainly  penetrate 
the  mucous  nionibrane,  wliicii,  if  swollen,  may  be  pushed  before  it;  i>ut  it  must 
not  be  thrust  in  too  deeply  lest  it  penetrate  the  posterior  wall  and  the  cesopha- 
gus;  if  the  lirst  opening  is  too  small,  it  nuist  be  enlarged. - 

If  there  is  not  immediate  danger,  proceed  as  follows:  the  patient 
being  in  j)Osition,  carefully  examine  the  region  and  determine  the 
precise  point  of  opening  the  tul)e;  make  a  straight  incision  exactly 
in  the  median  line,  extending  from  just  above  the  cricoid  cartilage, 
nearly  as  low  as  the  sternum;  if  the  patient  has  a  short,  fat  neck, 
make  the  first  incision  long  enough;  the  subcutaneous  fat  and  con- 
nective tissue  being  divided,  the  sterno-hyoid  muscles  are  exposed, 
divided  by  a  faint  line,  along  which  make  an  incision  dividing  the 
fascia ;  continue  the  dissection  cautiously  through  the  fascia  and  con- 
nective tissue,  layer  by  layer,  the  separated  tissues  being  held  aside, 
and  every  bleeding  vessel  secured  until  the  trachea  is  exposed  and 
opened. 

In  everj-  case,  however  apparently  hopeless  it  may  have  become,  the  operation 
should  be  completed,  and  the  tube  introduced,  even  though  the  patient  has 
ceased  to  breathe  before  this  can  be  accom|)lished  ;  the  most  persevering  efforts 

should  be  made  to  effect  resuscitation  by 
aid  of  artificial  respiration,  and  bv  suck- 
ing out  ihe  blood  that  may  have  entered 
the  trachea,  for  recovery  has  repeatedly 
been  effected  in  cases  apparently  the  most 
hopeless. 2 

Various  forms  of  tracheotomes  have 
been  contrived  to  render  the  operation 
more  easy  and  less  hazardous-*  (I'ig- 
478),  but  the  use  of  all  such  instruments  is  of  doubtful  propriety;  the  surgeon 
who  is  competent  to  operate  does  not  require  anything  of  the  kind, and  in  the 
hands  of  the  incompetent  they  are  likely  to  prove  dangerous.- 

The  last  stage  of  the  operation  varies  with  the  object  in  view  ;  if 
it  has  been  undertaken  on  account  of  the  presence  of  a  foreign  body, 
the  edges  of  the  opening  should  be  held  well  apart 
by  means  of  blunt  hooks,  or  dressing  forceps,  or 
silk  or  wire  ligatures  may  be  passed  through  each 
edge  of  the  wound, 
and  tied  behind  the 
neck  of  the  patient; 
if  the  body  is  com- 
paratively laru^e  and 
impacted  in  the  up- 
per part  of  tlie  tra- 


FiG.  479.'« 
chea,  it  is  better  to  introduce  a  canula  into  the  tracheal  wound,  and 
Sir  J.  Paget.  ^  A.  E.  Durham.  3  Von  Langenbeck;  Riitna. 


<  G.  Tiemann  &  Co. 


486 


OPERA  Tl  VE  S  UR  GER  Y. 


wait  until  all  spasm  has  had  time  to  subside;  if,  however,  the  body 
is  comparatively  small  and  is  situated  in  the  lower  part  of  the  trachea, 
it  is  better  to  lose  no  time  in  attempting  to  extract  it  by  means  of 
forceps,  lest  it  find  its  way  into  the  bronchi.^  The  forceps  best 
adapted  to  seize  the  body  has  a  peculiar  curve  (Fig.  479),  with 
broad  beaks.  Or,  it  may  have  a  pliable  shaft  which  can  be  bent  at 
any  curve,  and  will  retain  that  position  (Fig.  480);  when  introduced 
it  may  be  closed,  and  then  acts  as  a  probe;  if  the  foreign  body  is  felt, 
the  blades  can  be  gently  protruded,  and  when  they  inclose  the  body 
be  closed  upon  it,  and  removal  is  readily  effected.     If  the  operation 


Fig.  480.2 

is  undertaken  for  disease,  a  canula  should  be  selected  which  can  be 
worn  with  comfort,  and  which  will  be  least  liable  to  obstruction.  It 
should  always  be  double,  and  so  curved  as  not  to  jwess  upon  the 
anterior  wall  of  the  trachea. 

To  avoid  such  results,  the  external  canula  should  be  so  siiaped  as  to  pass  di- 
rectly backward  (Fig.  481),  and  lie  in  tlie  middle  of  the  trachea;  it  mu^^t  have 
a  collar,  through  which  the  tube  is  moved  by  a  screw,  held  in  place  by  alar  pro- 


FiG.  481. 


Fig.  482. 


Fig.  483. 


cesses,  which  pass  under  little  wire  arches;  the  inner  tube  has  a  jointed  ex- 
tremity (Fig.  483)  which  lies  in  the  trachea,  without  creating  any  irritation. l 
To  this  instrument  has  been  added  an  obdurator^  (Fig.  482),  which  renders  it  the 
most  perfect  instrument  yet  constructed. 

The  hard  rubber  canula  is  very  light  and  convenient,  but  does  not 
offer  any  special  advantages.  The  bivalve  canula  (Fig.  484)  is 
convenient  only  in  insertion  ;  the  two  halves  forming  a  wedge  along 

1  A.  E.  Durham.  2  (j.  Tiemann  &  Co.  ^  q.  Johnson. 


THE   TUACIIKA. 


487 


which  the  caniila  is  afterwards  passed.     The  canula  may  coiiieal  a 
hollow  trocar  (Fig.  4«5)  with  which  pcnelralion  is  effected. 


Fig.  487 


Fig.  484.  Fig.  485. 

The  introduction  of  the  caiuila  is  often  found  to  be  difficult,  and 

in   the   effort    it 

may    be     thrust 

into  the  cellular 

tissue.     Various 

instruments  have 

been  invented  to 
Fig.  48G.  aid  in  effecting  it,  as  guides  to  the  ca- 

uula;  as  forceps  (Fig.  48G),^  or  a  grooved  spatula 
(Fig.  487), 2  or  small  grooved  forceps  (Fig.  488), 
or  double  hooks,  worked  by  a  spring  (Fig.  48D).3 
Practically,  it  will  be  found  by  far  the  best  plan  to  ^^*^'-  ■*^^- 

use  the  canula  mounted  upon  a  blunt  pilot  trocar  (Fi"-.  490):  or  an 
elastic  catheter  or  bougie  may  be  used  as  a  substitute. 

'^^ 


m^ 


Fig.  489.  Fig.  490. 

The  after  treatment  •*  consists  in  closing  the  remaining  wound  with 
adhesive  plaster;  oiling  the  neck,  if  the  case  is  diphtheria;  maintain- 
ing a  warm  and  moist  atmosphere  ;  withdrawing  the  inner  tube  of 
the  canula,  cleaning,  and  replacing  it  after  it  is  well  oiled;  nourish- 
ing and  sustaining  the  patient. 

In  most  cases  in  which  tracheotomy  lias  been  performed  for  croup,  diphtheria, 
acute  huynfciti.s,  the  constant  attention  of  a  vigilant  and  skillful  nurse,  during  a 
!onpcr  or  sliorter  period,  is  absolutely  requisite;  the  superlative  importance  of 
careful  watoliincr,  judicious  management,  and  unwavering  perseverance  to  the 
very  end,  cannot  be  exaggerated. 

1  Trousseau.  '^  G.  Buck.  3  Vy„  Langenbeck.  ■*  A.  E.  Durliam. 


488  OPERATIVE   SURGERY. 

As  the  canula  exposes  the  patient  to  the  risk  of  bronchitis  and 
bronclio-pneumonia,  it  sliould  be  removed  at  the  earliest  possible  pe- 
riod ;  to  deterniiiie  how  necessary  the  instrument  is,  close  the  ex- 
ternal opening  from  time  to  time,  and  watch  the  effects ;  it  should 
not  be  withdrawn  unless  the  patient  can  breathe  for  some  hours  with 
the  orifice  plugged.  The  wound  usually  closes  rapidly,  after  the 
canula  is  removed. 

II.     THE    THYROID    BODY. 

This  body  is  situated  in  the  lower  part  of  the  neck,  and  embraces 
the  front  and  sides  of  the  upj)er  part  of  the  trachea. 

It  consists  of  two  lobes,  united  together  towards  their  lower  ends  by  a  trans- 
verse portion,  the  istlnnus;  each  lateral  lobe  is  two  inches  in  length,  an  inch 
and  a  quarter  in  breadth,  and  three  quarters  of  an  inch  in  thickness  at  its  largest 
part;  the  direction  of  eacli  lobe  is  from  below  obliquely  upwards  and  backwards, 
reaching  from  the  fifth  or  sixth  ring  of  the  trachea  to  the  posterior  border  of 
the  thyroid  cartilage;  the  isthmus  is  nearly  half  an  inch  in  breadth,  and  from 
a  quarter  to  three  quarters  of  an  inch  in  depth,  and  lies  across  the  third  and 
fourth  rings  of  the  trachea. i  In  structure,  it  consists  of  a  framework  of  con- 
nective tissue  condensed  externally  to  a  more  or  less  thick  investing  membrane, 
and  traversing  the  interior  of  the  organ  as  strong  trabecule,  and  of  gland  ves- 
icles, sustained  by  the  framework,  but  completely  closed  and  vesicular.2 

1.  Wounds  of  the  thyroid  are  followed  by  lijemorrhage;  ligate 
all  bleeding  arteries,  and  firmly  approximate  the  edges  with  sutures 
and  adhesive  strips. 

2.  Bronchocele,  goitre,  begins  as  an  hypertrophy  of  the  gland 
substance  or  proliferation  of  the  follicular  cells;  distinctions  are 
based  on  the  relative  share  taken  in  the  hyperplastic  process  by  other 
tissues,  namely,  if  the  stroma  develops,  the  tumor  has  a  soft  consist- 
ency; if  the  connective  tissue,  it  is  hard  and  fibroid;  if  the  arteries, 
it  has  a  pulsating,  aneurismal  character;  subsequent  changes  may  be 
attended  with  the  development  of  colloid  matter  in  the  follicles 
which  leads  to  excessive  enlargement,  and  by  its  softening  causes 
cysts,  or  with  amyloid  and  osseous  metamorphoses,  the  former  affect- 
ing the  glandular  parenchyma  and  vessels,  and  the  latter  the  con- 
nective tissue  and  stroma.^  The  various  kinds  of  bronchocele  are, 
therefore,  different  stages  of  development,  progressive  or  retrograde, 
of  the  simple  hypertrophiod  glan<l.^  The  treatment  depends  upon 
the  variety  under  observation:  — 

(1.)  Simple  bronchocele  mav  vary  in  size,  but  generally  retains  the  form  of 
the  thyroid  body,  if  soft,  and  is  rarely  more  than  an  inconvenience;  it  tends  to 
change  by  increase  of  the  fibrous  stroma;  the  treatment  is  iodine,  blisters,  and 
iron.  4 

(2.)  Fibrous  bronchocele  is  smooth,  hard,  and  unyielding,  may  be  small 
1  Quain's  Anat.  '•*  E.  Versou.  ^  e.  Rindfleisch.  *  M.  Jlackenzie. 


THE  BRONCHI.  489 

or  large,  and  ma)' involve  any  or  all  parts  of  the  gland;  the  treatment  is  the 
passage  of  a  seton  through  the  whole  substance  of  the  gland  transversely; 
twine  or  silk  may  be  used,  but  twine  is  preferable,  as  it  produces  suppuration 
more  quickly;  from  six  to  twelve  threads  are  used.i 

(3.)  Cystic  bronchocele  is  generally  a  blood-cyst  and  varies  in  size,  being 
sometimes  quite  small,  Init  niay  be  so  large  as  to  hang  down  in  front  of  the 
chest;  it  most  frequently  appears  in  the  isthmus,  but  may  occur  in  any  portion; 
the  form  is  globular,  or  ovoid,  some  cysts  are  movable,  others  are  lixed;  fluctua- 
tion may  be  distinct  or  imperceptible,  depending  ui)on  tlie  density  of  the  walls; 
the  treatment  consists  in  conversion  of  the  cy^t  into  a  chronic  abscess,  as  fol- 
lows: puncture  the  cyst  as  near  as  possible  to  the  median  line  and  at  tiie  most 
dependent  portion;  as  soon  as  the  trocar  is  felt  to  pierce  the  cyst  wall,  withdraw 
it  anil  pass  the  canula  deeper  b\'  means  of  a  blunt-pointed  key;  when  the  duid 
is  withdrawn,  inject  a  solution  of  perchloride  of  iron,  5  ij  to  aqua  ij;  insert  a 
plug  and  secure  the  canula  in  position  by  a  strip  of  adhesive  plaster;  repeat 
the  injection  at  intervals  of  two  or  three  days  until  suppuration  is  established, 
when  the  canula  should  be  removed  and  poultices  applied,  as  in  a  chronic  ab- 
scess; in  thirty-nine  ca-^es,  thirty -eight  were  cured;  ^  cases  which  have  resisted 
all  treatment  and  threaten  life  may  be  removed  by  injision.- 

3.  Excision  is  performed  by  observing  the  following  steps  of  the 
operation:  3  plaee  tlie  patient  on  a  firm  table,  with  tlie  liead  and 
shoulders  elevated  and  supported,  and  give  the  anaesthetic ;  make  an 
incision,  vertically,  of  ample  length,  avoiding  most  sedulously  any 
wounding  of  the  tumor  or  its  fascia  propria ;  divide  the  successive 
layers  of  fascia  upon  a  grooved  director  until  the  investm«'nt  of  the 
tumor  is  exposed;  reflect  tlie  investment  and  enucleate  the  tumor  as 
rapidly  as  possible  with  tlie  fingers  and  handle  of  the  scalpel,  paying 
no  attention  to  hajinonhage,  however  profuse,  but  going  as  lapidiy 
as  possible  to  the  base  of  the  gland  and  compressing  the  thyroid  ar- 
teries by  seizing  the  pedicles  with  the  fingers;  transfixion  of  the 
pedicle  from  below  upwards  with  a  blunt,  curved  needle,  armed  with 
a  double  ligature,  m:ide  of  eight  strands  of  saddler's  silk,  and  tying 
each  lialf,  or,  when  practicable,  dividing  the  pedicle  into  as  many  por- 
tions as  there  are  main  arterial  trunks,  and  tying  e;ieh  portion  sep- 
arately; excision  of  the  gland,  firm  ligature  of  all  bleeding  vessels, 
and  subsecpient  dressing  of  the  wounds,  is  as  in  ordinary  cases. 

III.     TIIE  BROXCIII. 

The  bronchi  commence  at  the  bifurcation  of  the  tracliea,  opposite 
the  third  dorsal  vertebrfe,  and  diverge  to  the  corresponding  lungs  ; 
the  right  is  wider  but  sliorter  than  the  left,  about  an  inch  in  length, 
and  passes  almost  horizontally  into  the  root  of  tlie  right  lung  on  a 
level  with  the  fourth  dorsal  vertebrje;  the  left  is  less  in  diameter, 
but  longer,  being  nearly  two  inches  in  length,  and  inclines  down- 
wards ;u)d  outwards  beneath  the  arch  of  the  aorta  to  the  root  of  the 

1  M.  Mackenzie.  -  W.  \V.  Gr.eiie;  T.  Holmes.  3  W.  W.  Greene. 


490  OPERATIVE  SURGERY. 

lung.i  The  ?eptum,  spur,  or  ridge  wliicli  separates  the  Ijronchi  at 
their  origin  is  not  in  the  median  hne,  but  decidedly  to  the  left  of  it.-' 
Foreign  bodies  passing  through  the  larynx  and  trachea  gen- 
erally enter  the  right  bronchus,  owing  to  the  peculiar  anatomical  ar- 
rangement at  the  bifurcation  ;  the  symptoms  ^  produced,  and  the  ob- 
struction to  respiration,  depend  upon  whether  the  substance  is  fixed 
or  movable,  its  size,  nature,  and  precise  position;  if  impacted  in  one 
of  the  bronchi,  the  entrance  of  air  into  the  corresponding  lung  is  more 
or  less  impeded,  or  the  obstruction  may  be  complete  with  entire  loss 
of  respiratory  murmur  on  the  affected  side;  the  body  may  not  occupy 
the  whole  calibre  of  the  bronchus,  when  the  vesicular  murmur  will 
be  diminished  ;  or  it  may  be  lodged  in  one  of  the  primary  or  second- 
ary divisions,  causing  an  entire  absence  of  the  murmur  over  a  certain 
limited  space;  natural  resonance  on  percussion  is  usually  preserved; 
but  as  a  rule  the  chest  rises  less,  during  inspiration,  on  the  affected 
than  on  the  sound  side,  and  the  respiration  is  puerile  in  the  ob- 
structed lung;  fixed  pain  referred  to  the  upper  part  of  the  chest 
when  the  body  is  immovable,  or  constant  pain,  with  a  sense  of 
weight  on  one  side,  sometimes  indicates  the  position  of  the  foreign 
body  ;  the  voice  may  be  hoarse,  the  respiration  wheezirig,  the  cough 
aggravated  by  deep  inspiration ;  inflammation  adds  to  these  symp- 
toms a  copious  and  offensive  expectoration,  paroxysms  of  fever,  night 
sweats,  and  exhaustion.*  When  the  symptoms  indicate  that  the  for- 
eign Ijody  is  in  one  of  the  bronchi,  tracheotomy  should  be  performed, 
and  the  opening  should  be  of  considerable  extent  and  as  low  down 
as  possible. ■*  The  removal  may  sometimes  be  effected,  if  the  foreign 
body  is  globular,  by  inversion  of  the  patient  and  giving  the  posterior 
walls  of  the  chest  a  blow,  but  care  must  be  taken  that  the  substance 
does  not  lodge  in  the  laryn.x,  and  cause  suffocation.  If  it  is  not 
dislodged  it  must  be  extracted  by  instruments;  first  explore  with  a 
long  probe  in  order  to  learn  the  exact  position  of  the  body,  then  in- 
troduce suitably  curved  forceps  and  seize  and  remove  it. 


CHAPTER   XLVL 

THE   LUNGS. 

These  organs  occupy  by  far  the  larger  part  of  the  cavity  of  the 
t;horax,  and,  during  life,  are  always  in  accurate  contact  with  the  in- 
ternal surface  of  its  wall. 

Each  luiif^  is  attached  at  a  comparatively  i^maW  part  of  its  inner  or  median 
surface  by  its  root;  the  pleurae  are  two  independent  shut  sacs  which  line  tha 
i  Quain's  Anatomy.    2  g.  d.  Gross.     3  J.  R.  Leaming.     *  A.  E.  Durham. 


THE  LUNGS.  491 

right  and  left  sides  of  the  thoracic  cavity;  each  pleura  receives  the  apex  of  the 
corresponding  lunf?,  and  projects,  in  the  form  of  a  cul-de-sac,  throiif;h  the  supe- 
rior aperture  of  tiie  thorax  into  tlie  neck.i  Tiiey  extend  an  inch,  and.  in  some 
cases,  even  two  inches  and  upwards,  above  the  niar;;in  of  the  lirst  rib.-  The 
rigiit  pleura  descends  to  the  lower  bolder  of  the  ninth  rib,  and  the  kft  to  the 
lower  border  of  the  tenth  rib.^ 

1.  Injuries  of  the  thoracic  parietes  are  important  only  as  they 
affect  the  contained  viscera.  These  wounds*  may  be  simple  con- 
tused wounds  of  the  soft  parietes,  contused  and  lacerated  wounds; 
or  accompanied  with  injury  to  bones  or  carlilajie;  or  complicated 
with  lesion  of  some  of  the  contents  of  the  chest,  the  jjleura  remain- 
ing unopened,  or,  if  opened,  without  a  superficial  wound.  In  the 
simpler  wounds,  in  which  the  soft  i)arietcs  only  are  involved,  the 
healiuii;  process  is  often  prolon^^ed  by  the  natural  movements  of  the 
ribs  to  which  the  wounded  structures  are  attached,  especially  when 
the  ball  has  taken  a  circuitous  course  beneath  the  skin,  and  the  sur- 
geon nmst  be  on  liis  guard  to  watch  for  pleuritis  arising  as  an  occa- 
sional consequence  of  these  injuries. 

When  the  force  has  been  great,  as  when  fragments  of  shell  or  rifle-balls  strike 
at  full  speed  against  a  man's  breast-plate,  not  only  may  troublesome  superficial 
abscesses  and  sinuses  follow,  but  the  lungs  mav  iiave  been  compressed  and  ec- 
chymosed  at  the  time  of  the  injury,  and  Invnioptysis  be  one  of  the  symptoms 
presented.  When  the  projectile  has  been  of  large  size,  although  no  opening  of 
the  parietes  or  fracture  exists,  death  sometimes  ensues  by  suffocation  as  the  di- 
rect result  of  pulmonary  engorgement.  The  danger  of  pleuritis  or  pneumonia 
will  be  greater  when  the  injury  has  been  so  severe  as  to  cause  division  of  bone 
or  cartilage,  and  the  subsequent  suppuration  and  process  of  exfoliation  will  not 
unfrequentlj'  prove  very  tedious  and  troublesome.  Although  the  pleura  has  not 
been  opened,  the  lung  may  be  lacerated  either  by  tlie  force  of  contusion  or  by 
the  edges  of  the  fractured  ribs,  which  may  afterwards  return  to  their  normal 
relative  positions,  so  as  to  leave  no  indication  during  life  of  the  means  by  which 
the  lung  had  been  wounded.  Such  an  injury  would  be  rendered  much  more 
probable  by  the  existence  of  old  adhesions,  connecting  the  pulmonary  and  cos- 
tal pleune  opposite  to  the  site  of  injury.  Notwithstanding  a  projectile  has  not 
penetrated  the  parietes  of  the  chest,  a  pleural  cavity  may  be  opened,  as  in  inju- 
ries from  other  causes,  and  the  lung  wounded  by  the  sharp  edges  of  fractured 
ribs.  This  will  be  indicated  by  enii)hysema,  pneumothorax,  luumoptysis,  prob- 
ably signs  of  internal  Inemorrhage,  and  inflannnation.  Such  wounds  will  gen- 
erally be  the  result  of  injuries  from  fragments  of  shell. 

2.  Wounds  of  the  pleura  ^  alone  are  ver)'  rare,  but  their  exist- 
ence has  been  demonstrated  by  actual  inspection  ;  they  must  be  diag- 
nosed by  the  absence  of  symptoms  of  wound  of  the  lung;  the  im- 
mediate complications  which  may  occur  are  lodgment  of  foreign 
bodies,  hajmathorax,  emphysema,  pneumothorax;  the  secondary 
effects  may  be  pleurisy,   hydro-thora.x,   empyema,  and   fistula.     In 

1  Qtuiiu's  Anatomy.  2  Q.  £.  Isaacs.  8  Luschka.         *  T.  Longmore. 

6  A.  Poland. 


492 


OPERATIVE  SURGERY. 


the  treatment,  all  manipulative  examination  is  to  be  denounced  as 
perfectly  unwarrantable;  beyond  the  removal  of  foreign  bodies,  the 
arrest  of  haemorrhage,  and  the  immediate  closure  of  the  external 
wound;  rest  and  quiet,  with  low  diet,  must  be  enforced,  and  the 
symptoms  watched  to  detect  the  occurrence  of  complications. 

3.  Foreign  bodies  lodged  in  the  thoracic  cavity  may  be  success- 
fully removed,  but  antiseptic  measures  should  be  persistently  em- 
ployed. 

A  slug  of  iron  from  a  bursting  gun  entered  the  left  chest  just  below  the  arm- 
pit, fracturing  the  sixth  rib,  and  lodged  beneath  the  heart  upon  the  vertebral 
column,  to  the  right  of  the  descending  aorta.  Seventy-four  days  after,  it  was 
removed  by  tlie  following  operation,  the  patient  being  extremely  prostrated:  An 
incision  three  inches  long  was  made  in  tlie  track  of  the  old  wound,  from  the  sev- 
enth over  the  sixth  and  tifth  ribs;  a  transverse  incision,  three  inches  long,  fol- 
lowed from  the  middle  of  the  tirst;  portions  of  the  tifth,  sixth,  and  seventh 
ribs  were  excised;  the  pleura  was  thickened,  the  lung  collapsed,  and  large  quan- 
tities of  pus  were  evacuated  during  the  search;  the  pulsations  of  the  heart  were 
strong  against  the  exploring  instrument,  and  the  foreign  body  was  at  length 
detected  under  that  organ,  and  was  removed  with  forceps;  a  rapid  recovery 
followed. 1 

4.  Paracentesis  thoracis,  tapping  the  pleural  cavity  to  withdraw 
fluid  accumulated  in  it,  is  required  :  "•^  (1)  In  pleurisy,  at  whatever 
date,  where  fluid  is  so  copious  as  to  fill  one  pleura,  and  begin  to  com- 
press the  lung  of  the  other  side,  for  in  all  such  cases  there  is  the 
possibility  of  sudden  and  fatal  orthopnoea ;  (2)  in  double  pleurisy, 
when  the  total  fluid  occtq)ies  a  space  equal  to  half  the  united  dimen- 
sions of  the  two  pleural  cavities ;  (3)  when  the  effusion  being  large, 
there  has  been  one  or  more  fits  of  orthopnoea ;  (4)  when  the  con- 
tained fluiil  is  purulent;  (5)  where  a  pleuritic  effusion,  occupying  as 
much  as  half  of  one  pleural  cavity,  has  existed  so  long  as  one  month 
and  shows  no  signs  of  progressive  absorption. 


Fig.  491.3 


The  instrument  consists  of  a  trocar  and  canula  *  (Fig.  491),  the  latter  being 
fitted  to  screw  upon  a  flexible  suction  tube  of  the  sj'ringe;^  the  canula  should 
be  provided  with  a  stop-cock;  the  trocar  and  canula  being  introduced  within  the 
1  E.  S.  Cooper.     2  p.  e.  Anstie.     3  Tiemann  &  Co.     *  a..  Flint,     s  Davidson. 


THE  LUNGS. 


493 


chest,  the  trocar  is  witlidrawn  and  the  canula  attached  to  tlie  syringe;  the  liquid 
is  then  removed  by  means  of  the  expansion  of  the  India-ruhher  suction  baj^  after 
its  compression  with  tiic  iiand.  Any  form  of  aspiratnr  may  l)e  u^ed,  or  tiie  com- 
mon trocar  and  canula;  but  in  the  latter  case  air  must  not  be  allowed  to  enter 
unless  antiseptic  spray  is  used. 

The  place  of  operation  will  vary  within  given  limits,  according  to 
the  amount  of  fluid  collected.  The  indications  are,  to  secure  a  suf- 
ficientlv  dei)ending  position  and  to  avoid  wounding  the  arteries  and 
tlie  diaphragm.'  In  general,  the  lower  portion  of  the  intercostal 
space  must  be  selected  as  the  intercostal  arteries  approach  the  cen- 
tres of  the  spaces  posterior  to  the  angles,  and  anterior  to  the  anterior 
third  of  the  spaces;  the  upper  limit  should  be  the  sixth  rib,  and  the 
lower  the  eighth  rib  on  the  right;  and  the  ninth  rib  on  the  left  (Fig. 
492).  The  point  to  be  selected  when 
there  are  no  special  indications  is,  the 
sixth  intercostal  space  on  the  right,  ^ 
owing  to  the  liver,  and  the  seventh  on 
the  left,  and  midway  between  the  spine 
and  the  sternum.  Some  ^  tap,  by  pref-  f 
erence,  below  the  angle  of  the  scapula 
and  between  the  seventh  and  eighth  '1 
ribs,  or  the  eighth  and  ninth  ribs,  at  a 
point  distant  from  two  to  three  inches 
from  the  angles. 

Operate  as  follows:^  Let  the  patient  sit 
across  the  bed  so  as  to  admit  of  the  body 
being  readily  lowered  and  supported  ovei 
the  edge;  carbolize  all  of  the  instruments; 
make  a  small  puncture  in  the  skin,  just  at 
the  upper  edge  of  the  rib,  with  a  narrow- 
bladed  lancet  or  knife;  puncture  the  cavity  through  this  incision, 
giving  the  instrument  a  slight  obliquity  upwards,  which  will  enable 
it  to  clear  the  edge  of  the  rib;  the  depth  to  which  the  trocar  or 
needle  penetrates  must  depend  on  the  thickness  of  the  parietes,  the 
presence  of  fat,  muscle,  or  oedema,  for  which  due  allowance  must  be 
made. 

Or,  find  the  inferior  limit  of  the  sound  lung  behind,  and  tap  two  inches  higher 
than  this  on  the  pleuritic  side,  at  a  point  in  a  line  let  fall  perpendicularly  from 
the  angle  of  the  scapula;  push  in  the  intercostal  space  here  with  the  point  of 
the  finger  and  plunge  the  trocar  quickly  in  at  the  depressed  part;  be  sure  to 
puncture  rapidly  and  to  a  sufficient  depth,  to  prevent  the  occlusion  of  the  ca- 
nula by  the  false  membrane. 3 

The  amoimt  of  fluid  withdrawn  in  any  case  must  depend  upon  the  condition 
of  the  patient  and  the   lungs,   care  always  being   taken   to   avoid  faintness.* 

1  A.  Polaud.  2  E.  Cock.  s  h.  I.  Bowditch.  *  T.  Watson. 


494  OPERATIl^  SURGERY. 

When  the  flow  ceases,  instantly  withdraw  the  canula,  and  place  the  point  of  the 
finger  on  the  puncture  until  adhesive  plaster  is  applied.  If  the  common  trocar 
and  canula  is  used,  the  outward  flow  of  fluid  must  not  be  allowed  to  intermit, 
lest  air  enter  the  cavity,  unless  the  carbolic  spray  is  in  use. 

5.  Concussion  of  the  lung^  mny  result  in  serious  functional  de- 
rangement without  organic  lesion;  it  may  be  transient,  and  subside 
without  ulterior  results,  or  it  may  be  succeeded  by  inflammation, 
either  local  or  general,  of  the  affected  lung.  There  are  no  special 
diagnostic  signs  except,  perhaps,  the  expectoration  of  blood-stained 
mucus  without  pneumonia  after  the  lapse  of  forty-eight  hours.  The 
treatment  should  aim,  (1)  to  relieve  the  shock,  and  (2)  then  the  en- 
gorged lung  by  leeches  over  the  part,  and  revulsives. 

6.  Wounds  of  the  lung,^  especially  when  the  projectile  lodges, 
are  necessarily  exceedingly  dangerous.  Fatal  consequences  are  to  be 
feared,  either  from  haemorrhage,  leading  to  exhaustion  or  suffocation; 
from  inflammation  of  the  pulmonary  structure  or  pleura? ;  from  irri- 
tative fever  accompanying  profuse  discharges ;  or  from  fluid  accumu- 
lations in  one  or  both  of  the  pleural  sacs.  When  the  chest  has  been 
opened  by  a  projectile,  the  following  signs  may  be  expected  in  addi- 
tion to  the  external  physical  evidences  of  the  injury:  namely  a 
certain  amount  of  constitutional  shock ;  collapse  from  loss  of  blood  ; 
and,  if  the  lung  be  wounded,  effusion  into  the  pleural  cavity,  haem- 
optysis, dyspnoea,  and  an  exsanguine  appearance. 

The  shock  of  penetrating  wounds  of  the  chest,  apart  from  the  collapse  conse- 
quent on  ha'niorrhage,  is  not  generallv  so  great  as  happens  in  extensive  injuries 
to  the  extremities  or  in  penetrating  wounds  of  the  abdomen.  When  loss  of 
blood  occurs  without  the  lung  being  wounded,  the  hiemorrhage  is  probably  pro- 
ceeding from  a  wound  of  one  of  the  intercostal  arteries,  which  has  been  torn  by 
the  sharp  ends  of  fractured  bone.  When  blood  is  effused  in  any  large  quantity 
into  the  pleural  sac  —  as  indicated  by  the  exsanguine  appearance  of  the  patient, 
increasing  dyspnoea,  occasional  hoemoptysis,  and  the  stethoscopic  signs  on  aus- 
cuhation  —  the  inference  is,  that  the  lung  has  been  opened,  and  that  it  is  from 
its  structure  the  blood  is  flowing.  Haemoptysis  indicates  injury  to  the  lung,  but 
does  not  give  assurance  that  this  organ  has  been  penetrated.  Dyspnoea  is  a  fre- 
quent accompaniment  of  wounds  penetrating  the  lung,  but  not  a  constant  symp- 
tom before  inflammatory  action  has  set  in.  When  dyspnoea  is  great  in  the  early 
period,  it  will  often  be  found  to  depend  upon  the  injuries  to  the  parietes,  and  on 
the  pain  caused  on  taking  a  full  inspiration.  If  air  and  froth}'  mucus,  with 
blood,  escape  bj-  the  wound,  there  can  be  no  doubt  of  the  nature  of  the  injury. 
Emphysema  is  not  common  in  penetrating  gunshot  wounds,  but  occasionally 
happens. 

The  treatment  must  in  the  first  place  be  the  arrest  of  ha?morrhage; 
afterwards  the  removal  of  pieces  or  jagged  projections  of  bone,  or 
any  other  sources  of  local  irritation.     Although  the  shock  may  hap- 
pen to  be  considerable,  attempts  to  rally  the  patient,  if  any  be  made, 
1  F.  Le  G.  Clarke.  2  x.  Longmore. 


THE  LUXGS.  495 

should  be  conducted  very  cautiously  ;  the  prolongation  of  the  de- 
pressed condition  may  be  valuable  in  enabliiijf  the  injured  structures 
to  assume  the  necessary  state  for  preventing  InvmonhaiC.  Haemor- 
rhage from  vessels  belonging  to  the  costal  paric-tes  should  be  arrested 
by  ligature,  as  in  other  parts,  if  the  source  from  which  it  proceeds 
can  be  ascertained,  and  if  the  flow  of  Ijlood  be  so  free  as  not  to  be 
controlled  by  ordinary  styptics.  Ilicmonhage  from  the  lung  itself 
must  be  treated  on  the  general  princij)!es  ailopted  in  all  such  cases  ; 
the  application  of  cold  to  the  chest,  perfect  quiet,  the  administration 
of  opium,  and,  if  the  patient  be  suHiciently  strong,  bleeding  from  a 
large  opening  until  syncope  supervenes.  A\  hen  blood  has  accumu- 
lated in  any  large  quantity,  and  the  patient  is  much  oppresseil,  the 
wound  should  be  eidar^ed,  if  necessary,  so  as,  with  the  assistance  of 
proper  position,  to  facilitate  its  escape.  If  the  effused  blood,  from 
the  situation  of  the  wound,  cannot  be  thus  evacuated,  and  the  pa- 
tient be  in  danger  of  suffocation,  then  the  performance  of  paracente- 
sis must  be  resorted  to. 

The  extensive  bleedings  formerly  recommended  in  all  penetrating  gunshot 
wounds  of  the  cht-st  are  now  praeliceil  witii  much  greater  limitations —  indeed, 
should  never  be  employed  simply  with  a  view  to  prevent  mischief  from  arising. 
Venesection  carried  to  a  great  extent  does  harm  by  lessening  the  restorative 
powers  of  the  frame.  To  remove  splinters  of  bone,  and  readjust  indented  por- 
tions of  the  ribs,  tlie  finger  should  be  introduced  into  the  wound,  care  being  taken 
that  in  doing  so  no  pieces  of  cloth  or  fragments  be  separated  and  projected  into 
the  pleural  sac.  Notice  must  at  the  same  time  be  taken  of  any  bleeding  vessel 
requiring  to  be  secured.  A  pledget  of  lint  should  be  laid  over  the  wound,  and 
a  broad  bandage  placed  round  the  chest,  just  tight  enough  to  support  tlie  ribs 
and  in  some  degree  to  restrain  their  movements,  but  with  an  opening  over  each 
wound  large  enough  to  permit  the  ready  access  of  the  surgeon  to  it  if  necessary. 
If  the  patient's  comfort  admits  of  it,  he  should  be  laid  with  the  wound  down- 
wards, with  a  view  to  prevent  accunnilalion  of  fluid  in  the  pleura;  and  if  there 
be  two  openings,  as  will  be  most  frequently  the  case  in  rifle-ball  wounds,  one 
wound  should  be  thus  placed,  and  the  uppnr  one  kept  covered.  In  gunshot 
wounds,  closure  of  the  parietes  by  adhesion  is  of  course  not  to  be  looked  for. 
If  the  presence  of  a  ball  within  the  cavity  be  ascertained,  efforts  should  be 
made  for  its  removal;  but  any  attempt  to  determine  where  the  ball  has  lodged 
should  be  made  very  cautiously,  as  more  harm  may  result  from  the  interference 
than  from  the  lodgment  of  the  foreign  body. 

(1.)  Pneumocele,  hernia  of  the  lung,  sometimes  occurs.  If  the  protruded 
portion  is  uninjured,  and  healthy  in  appearance,  it  may  be  reduced  by  moderate 
manipulation,  care  being  taken  not  to  injure  its  delicate  structure;  if  reduction 
is  impossible,  owing  to  constriction,  and  the  protruded  part  is  formed  of  soft 
structures,  the  neck  may  be  cautiously  divided,  care  being  taken  to  avoid 
wounding  the  lung  or  intercostal  vessels;  if  the  lung  is  gangrenous,  it  may  be 
left  to  slough  or  an  elastic  ligature  may  be  applied. 

(2.)  Smphysema,  the  infiltration  of  air  into  the  subcutaneous  cellular  tissue, 
may  occur,  recognized  by  tlie  crepitating  feeling  under  pressure.  The  treat- 
ment is  pre.ssure,  if  it  is  well  borne;  punctures  and  incisions  are  rarely  required. 


496  OPERATIVE  SURGERY. 

The  air  may  be  confined  to  the  cavity  of  the  pleura,  pneumothorax.  If  the 
oppression  of  the  breathing  is  very  great,  open  tlie  wound;  or,  if  there  is  no 
wound,  puncture  with  a  trocar  and  canula. 

(3.)  Hsemo-thorax,  haemorrhage  into  the  cavitj'  of  the  pleura,  may  be  so 
great  tiiat  death  ensues  from  the  loss  of  blood  and  pressure  on  the  lungs.  The 
signs  of  severe  h;emorrhage  are,  great  oppression,  restlessness,  sitting  up  in 
bed  the  body  bent  forwards,  countenance  cold  and  pale;  then  follows  syncope 
and  utter  prostration,  the  patient  lying  almost  motionless,  with  occasional  heav- 
ing of  the  chest.  The  most  judicious  treatment  is,  at  tirst,  to  close  the  external 
wounil,  and  allow  the  effused  blood  to  coagulate,  if  possible,  with  a  view  to  its 
ultimate  absorption.  But  if  the  effusion  increases,  and  causes  the  dangerous 
symptoms  given,  the  external  wound  may  be  kept  open  or  enlarged  to  allow 
the  escape  of  the  blood  by  position  of  the  body;  or  the  chest  may  be  opened  at 
a  more  dependent  part;  no  attempt  should  be  made  to  pump  out  the  blood,  or 
to  soften  the  clot  b_v  injection  of  fluids. 

7.  Puncture  of  cavities  of  the  lung  has  been  frequently  advised, ^ 
and  many  times  performed  with  a  view  to  evacuate  the  pus,  and  also 
to  inject  the  cavities  with  medicated  fluids.  The  results  have  not 
been  such  as  to  establish  the  value  of  the  operation.  The  fluids  in- 
jected have  been  five  to  ten  minims  of  a  dilute  solution  of  permangan- 
ate of  potassa;^  or  sol.  carbolic  acid  and  tr.  iodine;  or  Lugol's  sol. 
iodine.^  The  operation  has  been  performed  as  follows:^  The  long 
duration  of  the  affection  was  relied  on  to  form  adhesions  between  the 
two  layers  of  the  pleura  at  the  point  selected;  an  incision  was  then 
made  throunh  the  skin  and  superficial  intercostal  muscles,  commen- 
cing about  two  inches  front  the  right  border  of  tbe  sternum  and  along 
the  upper  border  of  the  third  rib;  the  cavity  was  now  opened  with  a 
suitable  pair  of  forceps  penetrating  more  and  more  deeply  into  the 
bottom  of  the  wound  ;  a  drainage  tube  was  introduced  and  fastened 
to  the  wall ;  Or  a  small  trocar  canula  may  be  employed  ;  Or  a 
small  aspirating  needle  may  be  used,  with  the  vacuum  formed,  at- 
tached, especially  in  the  first  or  exploratory  operation. 

8.  Circumscribed  collections  of  pus  ^  frequently  form  in  the 
pleural  cavities  of  children,  attended  by  cough  and  great  emaciation; 
these  cases  are  often  mistaken  for  pulmonary  phthisis,  and  prove 
fatal  by  ])enetrating  the  lung,  or  by  exhaustion.  The  proper  treat- 
ment is.  early  evacuation  of  the  pus  by  aspiration,  or  incision.  The 
abscess  being  carefully  localized  by  percussion,  make  an  incision  and 
puncture  over  the  upper  margin  of  the  rib;  the  track  of  the  wound 
may  be  left  open.  The  relief  is  usually  immediate  and  recovery 
prompt. 

1  Barry  ;  Massy ;  Hooken.        2  \\,  Hosier.        »  W.  Pepper.        ^  C.  Hiiter. 
6  J.  L.  Smith. 


IX. 

THE    URINARY    ORGANS. 


CHAPTER    XLVir. 


i 


THE    KIDNEYS. 

These  ororans^  lie  at  the  back  of  the  abdomen  (Fig.  493),  on  the 
quadratus  hmiboriim  and  psoas  muscles,  opposite  the  two  lower  dorsal 
and  two  upper  lumbar  vertebrae ;  the  right  is   .\  . 

a  trifle  lower  than  the  left,  owing  to  the  size  of  ^^       m\ 
the  liver;  the  pelvis  of  the  kidney  is  about  the 
level  of  the  spine  of  the  first  lumbar  vertebra; 
the  upper  border  is  about  the  level  of  the  space      \~^   cjr^  ^F^ 
between  the  eleventh  and  twelfth  dorsal  spines;      \y<^^   "^ii^ }     >"- 
the  lower  border  is  as  low  as  the  third  lumbar     )''  "^\^0 '.(/''    '\ 
spine. 

Durinf;  a  deep  inspiration  both  kidneys  are  depressed 
by  the  diapiirasrm  nearly  half  an  inch;  the  healthy  kid- 
ney cannot  be  felt  by  external  examination,  but  the 
degree  of  enlargement  and  tenderness  may  be  deter- 
mined; care  must  be  taken  not  to  mistake  for  the  kid- 
ney an  enlarged  liver,  or  spleen,  or  accumulation  of  fteces  in  the  lumbar  colon. 

1.  Rupture  of  the  kidney  is  not  necessarily  fatal;  its  severity 
depends  upon  its  location  and  extent,  for  it  may  involve  the  external 
covering,  or  be  entirely  internal.  When  the  lesion  is  confined  to 
the  anterior  surface,  urine  may  escape,  and  cause  acute  and  rapidly 
fatal  peritonitis ;  if  limited  to  the  posterior  surface,  and  urine  escape 
into  the  sub-serous  cellular  tissue,  suppurative  inflammation  is  very 
liable  to  be  established,  with  rigors,  high  fever,  typhoid  tongue,  and 
oedema  of  the  parts;  if  the  rupture  is  internal,  abscess  m.iy  occur.'* 
Blood  may  appear  in  the  urine  at  once  or  after  several  days;  if  a 
small  amount  pass  with  the  water,  the  rupture  will  not  prove  serious, 
for  this  symptom  often  follows  bruises  of  the  kidneys;  but  when  the 
J  L.  Holden.  2  j.  Birkett. 

32 


498  OPERATIVE   SURGERY. 

ha?morrhagc  is  (.'opious  and  persistent,  or  recurrent,  accompanied 
Avith  ])i\in,  especially  if  followed  by  suppuration,  the  injury  is  seri- 
ous.^ The  treatment  should  be  rest;  opium,  to  relieve  pain,  and 
quinine,  in  full  doses,  if  tlie  fever  is  marked. 

A  constant  watcli  must  be  maintained  of  the  lumbar  and  iliac  regions  to  detect 
the  appearance  of  swelling,  in  order  to  be  iirejiared  for  the  early  evacuation  of 
pus.  A  premature  opening,  in  anticipation  of  the  formation  of  matter,  is  prefer- 
able to  delay  in  giving  it  vent  when  once  established,  for  suppuration  in  the 
lumbar  region  spreads  rapidly  and  produces  intense  constitutional  disturbance.! 

2.  Abscess  of  the  kidney  may  follow  an  injury,  as  rupture,  or 
may  result  from  interstitial  nephritis  or  embolism;  tlie  kidney  is 
markedly  enlarged;  its  capsule  and  the  adipose  tissue  in  which  it 
lies  are  congested  and  oedematous ;  beginning  as  a  superficial  affec- 
tion, it  no  sooner  extends  to  the  renal  parenchyma  tlian  it  involves 
all  the  connective  tissue  of  tlie  kidney;  and  this,  in  turn,  culminates 
in  suppuration  at  various  points;  tlie  pus  may  even  make  its  Avay 
througlr  a  rent  in  the  capsule  and  lead  to  the  formation  of  dependent 
abscesses  in  the  retro-peritoneal  connective  tissue.'^  The  diagnosis  ^ 
of  traumatic  nepliritis  rests  upon  the  liistory  of  the  injury,  and  the 
passage  at  first  of  blood  and  afterwards  of  pus  in  the  urine,  to  which 
are  added  great  local  tenderness,  chills  with  fever,  dull  or  sharp 
pains  through  the  part  affected,  and  finally  a  tumor  perceptible  on 
examination. 

Wiien  the  abscess  is  idiopathic,  and  no  adequate  cause  can  be  discovered, 
the  diagnosis  is  exceedingly  difficult,  and  frequent!}^  even  impossible,  not  onlj' 
in  its  early  stages,  but  throughout  its  course;  fever,  occasional  chills,  gastric 
disturbances,  vomiting,  loss  of  appetite,  and  diarrlioea,  are  often  the  only  ob- 
jective symptoms;  it  is  only  when,  in  addition  to  tliose  symptoms,  there  is  ten- 
derness over  the  region  of  the  kidney,  and  a  tumor  can  be  made  out  which  is 
evidently  connected  with  that  organ,  or  when  rupture  of  the  abscess  occurs, 
tliat  a  diagnosis  becomes  possible. 3 

AVhen  the  suppuration  continues,  in  spite  of  well-directed  efforts 
to  control  its  progress,  the  (juestion  of  the  evacuation  of  the  contents 
of  the  abscess,  by  incision,  must  be  decided. 

The  following  rules*  defining  the  conditions  under  which  neplirotomy  is  not 
proper,  are  perfectly  good,^  and  should  be  dub*  considered:  (1)  When  there  is 
reason  to  su])pose  that  both  kidneys  are  diseased;  (2)  when  the  pus  finds  free' 
exit  by  the  bladder,  no  renal  tiunor  exists,  and  the  other  kidney  is  performing 
its  function  satisfactorily;  (3)  when  the  bladder  or  prostate  are  incurably  dis- 
eased, or  grave  lesions  of  other  viscera  exist. 

3.  Pe rill ephri tic  abscess  may  result  from  injury,  abscess  of  the 
kidney,  or  from  unknown  causes;  it  consists  in  the  formation  of  pus 
in  the  connective  tissue  around  the  kidney.     The  symptoms  are  pain 

1  F.  Le  G.  Clarke.  2  e.  Rindfleisch.         3  \v.  Ebstein.  -»  M.  Rayer. 

6  Van  Buren  and  Keyes. 


THE   KIDXEYS.  499 

in  the  vicinity  of  the  kidney,  rapid  j)iilse,  fever,  swelling  in  the  hini- 
bar  and  iliac  region,  which  has  a  don;4hy  feeling.  As  the  disease 
progresses,  the  tumor  enlarges,  frequently  filling  up  the  iliac  fossa 
and  protruding  under  Ponpart's  ligament  or  along  the  edge  of  the 
ilium;  it  may  also  pass  upwards  behind  the  peritoneum,  and,  pene- 
trating the  diaphragm,  form  connections  with  the  lun'j:,  and  finally 
discharge  through  it,  or  it  may  find  an  outlet  for  its  contents  into  the 
bowels,  rectum,  bladder,  or  vagina.  The  early  treatment  must  aim 
to  subdue  the  inflammation  by  absolute  rest,  laxatives,  or  enemata; 
leeching,  opium  to  -elieve  pair  with  quinine  and  nourishing  food; 
auscultation  of  the  lung  should  b^  frequently  practiced,  especially  in 
obscure  cases,  to  anticipate  any  tendency  of  the  pus  to  find  its  way 
out  in  that  direction.^  Constant  attention  must  be  given  to  the  for- 
mation of  the  characteristic  enlargement  in  the  lumbar  reirion;  when 
this  appears  and  the  nature  of  the  disease  becomes  manifest,  an  early 
operation  is  demanded ;i  for  a  premature  opening,  in  anticipation  of 
the  formation  of  matter,  is  better  than  that  any  delay  should  occur 
in  giving  exit  to  the  pus.'^  The  point  of  opera-  ^ 
tion  should  be,  as  a  rule,  in  the  renal  region  (Fig.  /S 
493),  to  avoid  the  peritoneum,  and  where  fluctu- , 
ation  is  most  distinct,  unless  the  abscess  point  be- 
low, as  along  the  ilium,  or  at  Poupart's  ligament; 
if  the  swelling  is  defined,  and  the  abscess  shows, 
no  sign  of  pointing,  select  the  margin  of  the  quad-  \Sv;'^ 
ratus  lumboruni,  or  a  point  midway  between  the  k!^'^^^^^^^ / // 
last  rib  and  ilium,  on  a  line  vertical  to  the  centre 'O^'  ' 

of  the  ilium,  1  (Fig.  494);  introduce  an  aspirating  ^ 

needle,  and  if  pus  is  found,  make  this  the  guide 
to  a  straight,  narrow-bladed  knife,  and  open  the  swelling  freely;  if 
pus  is  not  found,  carefully  dissect  the  parts  by  transverse  incisions 
through  the  skin,  fascia?,  and  connective  tissue,  until  the  abscess  is 
reached,  when  it  should  be  opened  ;  if  no  pus  is  found,  the  wound 
should  still  be  kept  open  for  the  purpose  of  securing  the  early  escape 
of  the  first-formed  pus.  The  outflow  of  pus  once  secured,  must  be 
maintained  by  tents,  if  necessary,  and  carbolized  solutions  must  be 
freely  injected  to  preserve  the  abscess  from  the  irritation  of  retained 
septic  fluids. 

4.  Calculus  in  the  kidney  ^  is  a  concretion  caused  by  the  deposit 
of  the  salts  of  the  urine  in  the  pelvis  of  that  organ. 

Renal  stones  are  sometimes  found  sinfrly,  and  apraiii  in  considerable  numbers; 

they  vary  much  in  number  and  size,  beinp  generally  small,  but  thcv  niav  be  so 

large  as  to  adapt  tliemselves  to  the  renal  pelvis  and  calyces,  and  branch  like 

coral,  the  number  varying  according  as  they  include  a  larger  or  smaller  num- 

1  H.  I.  liowditch.  2  J.  Birkett.  s  w.  Ebstein. 


500  OPERATIVE  SURGERY. 

ber  of  calj'ces.  The  greater  number  of  stones  pass  through  the  ureter  into  the 
bladder,  and  this  is  the  most  common  termination  of  nephrolithiasis;  but  some- 
times a  stone  becomes  so  large  that  it  cannot  pass  the  ureter;  it  then  continues 
to  grow,  at  first  filling  the  renal  pelvis  partly,  afterwards  entirelj',  and  sometimes 
the  cal3'ces;  the  urine  secreted  above  the  stone  is  dammed  up  in  proportion  to 
the  amount  of  hindrance  offered  to  its  escape,  exercising  considerable  pressure 
on  the  renal  tissue,  Avhich  leads  to  atrophy  of  the  parencliynui,  and  sometimes  to 
complete  disappearance  of  the  organ,  its  place  being  tilled  by  a  membranous 
sac.     The  presence  of  renal  sand  is  only  learned  by  proper  tests  of  the  urine. 

The  symptoms  caused  by  larger  concretions,  though  sometimes 
absent,  are  usually  distinct  and  often  very  characteristic.  In  general, 
there  is  pain,  sometimes  cutting  or  piercing,  in  the  loins,  or  attended 
by  a  continual  sense  of  pressure  or  tension.  There  may  be  violent 
paroxysms,  renal  colic,  excited  by  jarring  motions;  the  pain  extends 
along  the  ureter  and  spreads  over  tlie  abdomen,  or  radiates  to  other 
parts  of  the  body,  as  the  testicle,  thigh,  breast,  shoulder;  every 
movement  is  torture  and  the  patient  bends  double,  or  lies  on  the  af- 
fected side  with  the  knees  drawn  up;  vomiting  occurs,  and  severe 
strangury,  the  urine  being  scanty,  red,  brown,  or  blackish,  or  loaded 
with  blood,  mingled  with  pus  and  mucus.  The  diagnosis  rests  upon 
those  symptoms  pointing  directly  to  the  kidney  involved,  and  the 
behavior  of  the  lu'inary  secretion  during  an  attack.  The  treatment 
should  be  directed  (1)  to  prevent  the  formation  of  renal  sand  and 
gravel,  and  (2)  to  remove  the  already  formed  precipitates.  As  a 
rich  or  exclusively  flesh  diet  promotes  the  formation  of  renal  sand,  es- 
pecially uric  acid,  simple  and  easily  digestible  foods  should  be  substi- 
tuted, with  active  out-of-door  exercise.  The  medicinal  remedies  of 
greatest  value  are  alkalies  and  alkaline  salts,  as  the  bicarbonate  of 
soda,  carbonate  of  potash,  carbonate  of  lithia,  or  the  mineral  waters 
of  Vichy;  they  must  not  be  taken  in  such  quantities  as  to  render 
the  urine  alkaline;  otherwise  earthy  phosphates  will  be  precipitated. 
If,  however,  the  concretion  forms  in  the  kidney,  efforts  must  be 
made  to  relieve  its  effects.  The  paroxysms  of  pain  must  be  relieved 
by  opium  or  its  salts;  the  hypodermic  injection  of  morphia  is  gener- 
ally most  serviceable;  an  enema  of  laudanum  is  often  useful,  with 
anodyne  applications.  Extreme  heat,  as  a  very  hot  brick,  heated 
sand,  or  salt  bag,  or  bottle  of  boiling  water,  well  wrapped,  is  very 
soothing;  an  anaesthetic  may  occasionally  be  necessary;  chloral, 
with  morphia,  sometimes  acts  very  favorably.  Should  the  presence 
of  the  stone  cause  suppuration,  with  a  well-defined  timior,  the  pus 
must  be  early  evacuated,  at  first  by  aspiration,  and  then  by  incision, 
as  in  the  case  of  perinephritic  abscess.  But  the  still  more  important 
operation  of  nephrotomy,  incision  of  the  kidney,  for  the  removal  of 
the  stone,  must  now  be  duly  considered,  and  even  extirpation  of  the 
kidney  may  become  justifiable. 


THE  KIDNEYS. 


501 


5.  Hydronephrosis  ^  consists  of  a  dilatation  of  the  pelvis  of  tlie 
kidney  and  subsequent  more  or  less  extensive  disappearance  of  the 
renal  parenchyma,  due  to  obstacles  to  the  escape  of  the  urine  in 
any  division  of  the  urinary  passages;  it  may  be  congenital  and  non- 
congenital,  the  former  being  due  to  malformations,  and  the  latter  to 
concretions  wedged  into  the  pelvis  or  the  ureter,  or  pressure  from 
various  causes  upon  the  urinary  track.  The  symptoms  depend  upon 
the  grade  of  distention,  and  the  invasion  of  one  or  l)Oth  kidneys; 
if  the  obstruction  is  considerable,  and  especially  if  both  organs  are 
involved,  the  symptoms  are  those  of  embarrassed,  diminished,  or  ar- 
rested activity  of  the  kidneys,  namely,  acute  or  chronic  uraemia. 
The  tumor  caused  by  distention  of  the  kidney  may  attain  a  very 
large  size,  is  generally  unilateral,  and  occupies  the  loins,  extendinor 
to  the  vertebral  column,  and  often  upwards  into  the  liypocliondrium, 
downwards  into  the  iliac  region,  and  forward  to  the  umbilicus;  it  is 
soft,  dull  on  percussion,  distinctly  defined  by  palpation,  gives  a  dis- 
tinct sense  of  fluctuation,  is  not  movable,  generally  painless,  and 
causes  no  feeling  of  inconvenience  except  that  of  weight  and  tension; 
if  caused  by  nephrolithiasis,  there 
will  be  attacks  of  renal  colic,  with 
bloody  urine.  The  disease  may  be 
diagnosed  from  ovarian  c^'sts  by 
rectal  examination  with  the  hand, 
and  from  other  tumors  by  the 
method  of  exclusion.  The  treat- 
ment in  the  early  stages  is  expect- 
ant; whore,  however,  the  tumor  is 
large  and  affects  the  health,  as  by 
embarrassing  respiration,  it  may 
become  necessary  to  remove  the 
fluid  ;  this  has  been  efTected  by 
repeated  kneading  of  the  tumor 
which  resulted  in  the  escape  of  a 
large  quantity  of  urine,  and  appar- 
ent recovery.2  Usually,  evacuation 
is  best  effected  by  aspiration,  but 
the  operation  is  not  free  from  dan- 
ger. 

The  aspirator  is  designed  to  remove 
fluids  from  cavities  by  means  of  capillary 
tubes  and  a  siiotion-piimp,  so  as  not  to  leave  an  open  wound  nor  admit  air  to 
tile  cavity.  Various  forms  of  aspirators  are  now  in  use  wliicii  answer  every 
pur[)ose,  i)ut  none  are  as  tliorouglily  effective  as  that  originally  introduce<l  into 
practice  (Fig.  41)5).'^ 

1  W.  Ebsiein.  2  Koberts.  «  M.  Dieulafov. 


-W~h'^ 


■<ifiS) 


Fig.  495. 


502  OPERATIVE  SURGERY. 

It  consists  of  a  glass  cylinder,  a,  about  seven  inches  in  height,  and  two  in  di- 
ameter, partly  covered  with  a  silver-plated  casing,  and  having  a  tightly  fit- 
ting piston  which  is  raised  or  lowered  by  turning  the  handle,  b.  Near  the  bot- 
tom of  the  cylinder  are  the  induction  and  eduction  openings,  d  c,  titled  with 
rubber  tubes.  The  capillary  tubes  or  trocars  are  six  in  number,  and  of  different 
sizes;  one  is  shown  attached  to  the  induction-tube,  d,  and  five  below  the  instru- 
ment. In  addition  to  these  there  should  be  two  or  three  small  blunt  canulas 
with  trocars  and  a  detacliable  handle,  so  that  when  the  trocar  is  witiidrawn  the 
canula  may  be  attached  to  the  instrument.  In  using  the  instrument,  the  cocks, 
c  d,  are  closed,  and  the  handle,  b,  turned,  producing  a  nearly  perfect  vacuum  in 
the  cylinder;  the  piston  is  held  in  raised  position  by  a  spring,  e.  The  trocar  is 
introduced  with  a  rotary  motion  into  the  part  from  which  the  fluid  is  to  be  with- 
drawn; on  opening  the  cock,  d,  it  tiows  into  the  cylinder,  which  is  emptied 
when  full  by  closing  d,  opening  c,  pulling  out  the  spring,  e,  and  lowering  the 
piston;  when  this  is  done,  both  cocks  are  again  closed,  and  the  operation  re- 
peated. The  cylinder  is  provided  with  a  scale  graduated  to  grams,  for  show- 
ing the  amount  of  contained  fluid,  and  a  glass  tube  is  inserted  near  the  outer 
end  of  the  induction-tube,  through  which  the  fluid  may  be  inspected.  Very 
cheap  and  simple  aspirators  may  now  be  obtained,  which  are  portable,  and  will 
answer  in  ordinary  cases.  Perhaps  the  most  simple  instrument  which  the  prac- 
titioner can  employ  for  aspiration  consists  of  several  sizes  of  needles  to  which 
the  syringe  with  a  rubber  tube  and  bulb  i  is  fitted;  the  needle  being  intniduced 
into  the  cavity,  with  the  tube  drawn  over  its  outer  extremity,  by  squeezing  the 
bulb  the  fluid  is  forcibly  and  rapidly  drawn  out. 

The  point  selected  for  aspiration  will  depend  upon  the  size  and 
form  of  the  tumor.  In  general,  the  space  between  the  eleventh  and 
twelfth  ribs  crives  the  most  direct  access  to  the  cavity  of  the  tumor, 
and  is  least  lial)le  to  involve  the  peritoneum.^ 

The  cavity  has  been  opened  bj'  incision;  3  two  trocars  were  introduced  near 
together  and  allowed  to  remain  fom-  days;  on  the  third  day  urine  flowed  by  the 
side  of  tlie  canula,  and  on  the  fourth  a  chill  occurred;  an  incision  was  now 
made  between  the  trocars,-*  which  were  rem,. 'ed,  the  fluid  evacuated,  and  drain- 
age established,  with  carbolic  acid  dressings;  death  took  place  on  the  sixth  day; 
the  kidney  has  also  been  extirpated  for  this  disease, ^  but  with  fatal  results. 


CHAPTER  XLVIII. 
THE    URINARY    BLADDER. 

During  infancy  the  bladder  is  pyriforni  and  lies  chiefly  in  the 
abdomen,  but  in  the  adult  it  is  situated  in  the  pelvic  cavity  behind 
the  pubes;  in  the  male  it  is  in  front  of  the  rectuiu,  and  in  the  female 
the  uterus  and  vagina  are  interposed  between  it  and  the  rectum. 

When  quite  eniptj'  the  bladder  lies  deeply  in  the  pelvis,  when  moderately  full 
it  is  still  in  the  ]ielvic  cavity  and  has  a  rounded  form,  and  when  completely  dis- 
tended it  rises  above  the  brim  of  the  pelvis  and  becomes  egg-shaped;  the  base 
is  directed  towards  the  rectum  in  the  male,  and  the  vagina  in  the  female,  and 

1  Davidson.  2  j.  Thompson..         3  Maas.  ^  Simon.         ^  Schetelig. 


THE   URINARY  BLADDER. 


503 


Fig.  496. 


the  smaller  end  or  summit  rests  against  the  lower  part  of  the  anterior  wall  of  the 
abdomen;  the  anterior  surface  is  entirely  destitute  of  peritoneum,  while  the  pos- 
terior is  covere<l  by  the  peritoneum,  which  is  prolonged  upon  the  hase;  the  dis- 
tended bladder  has  its  long  axis  inclined  ujtwards  and  forwards  in  a  line  from 
the  coccyx  to  a  point  between  the  umbilicus  anil  pubes.i 

I.     EXPLOIIATIOX. 
Tlie  cavity  of  the  bladilrr  may  \w  explored  to  determine  (1)  its 
fluid  contents,   with  catheters;  (2)  its  solid  contents,  with  sounds; 
(3)  the  chancres  in  its  mucous  liniuif,  with  the  endoscope. 

1.  The  catheter  is  a  tube  composed  either  of  metal,  or  soft  ma- 
terial ;  the  former  is  inelastic,  while  the  latter  is  flexible.  In  prac- 
tice, the  metallic  catheter  is  now  seldom  employed  to  draw  off  urine, 
for  with  the  improved  gum  catheter  this  is  done  more  safely,  speed- 
ily, and  conveniently.^ 

The  gum-elastic  catheter  is  made  of 
every  needful  size,  and  may  have  a 
rouniled,  a,  or  an  olivary  extremity,  b 
(Fig.  4'JG)  Its  great  advantage  over  the 
metallic  instrument  is,  that  ordinarily 
there  is  no  great  skill  required  in  using 
it,  and  no  danger  is  to  be  apprehended  of  lacerating  the  mucous  membrane.- 

The  soft  rubber  catheter  is  a  per- 
fectly harmless  instrument,  even  in 
the  hands  of  patients,  and  is  adaptea 
to  cases  in  which  the  urethra  has  an 
irregular  course. 

In  selecting  a  metallic  instrument, 
the  following  facts  should  be  borne  in 
mind  :  3  the  instrument  should  be 
made  of  silver,  and  curved  so  as  to  be 
exactly  adapted  to  the  natural  curve 
of  the  urethra  in  its  least  movable 
portion,  which  may  be  supposed  to 
have  its  axis  in  the  centre  of  the  sym- 
physis pubis;3  this  curve  is  equal  to 
a  portion  of  a  circumferential  line, 
equal  to  alx)ut  three  tenths  of  a  circle 
three  inches  and  a  quarter*  in  diam- 
eter. It  is  also  important  that  the 
direction  of  the  axis  of  the  point 
should  be  at  right  angles  to  that  of 
tlie  shaft,  whatever  may  be  the  length 
of  the  curve; 3  the  operator  can  then 
always  determine  exactly  the  position 
uf  the  point,  however  deeply  the  instrument  may  have  penetrated.  The  handle 
of  the  instrument  should  have  a  ring  on  each  side,  near  the  external  extremity, 
which  are  useful  as  guides  to  the  position  of  the  instruments,  as  aids  in  detect- 
ing obstructions,  and  as  means  of  securing  the  instrument  in  the  bladder.     The 

1  Quains  Aiiat.        -  J.  \\.  S.  Gouley.         3  gir  II.  Thompson.         *  Briggs. 


504 


OPERATIVE  SURGERY. 


Fig.  498. 


eye  should  not  be  so  lai-ge  as  to  catch  the  mucous  membrane.  The  gum  cathe- 
ter takes  many  forms  adapted  to  special  conditions;  it  may  be  made  self-retain- 
ing by  enlargements,  or  projections  on  its  internal  extremity  (Fig.  497). 

The  introduction  of  the  catheter,  although  apparently  very  simple, 
is  one  of  the  nicest  and  most  delicate  processes  in  surgery. ^  Pro- 
ceed as  follows 
(Fig.  4  9  8):  place 
the  patient  in 
the  recumbent 
position,  with 
the  head  and 
shoulders 
slightly  ele- 
vated by  pil- 
lows, the  knees 
a  little  raised 
and  separated 
from  each  other 
to  relax  the 
muscles  of  the 
ahdoinen      and 

perineum ;  standing  or  sitting  on  the  left  side  of  the  couch,  with 
the  left  hand  support  the  penis,  grasped  by  the  thumb  on  one 
side  and  the  fore  and  middle  finger  on  the  other,  or  with  the 
palm  upwards  raise  the  penis  between  the  ring  and  middle  fingers 
applied  just  behind  the  corona  glandi-j;  with  the  thumb  and  the 
fore  and  middle  fingers  of  the  right,  seize  the  catheter,  warmed 
and  well  smeared  with  oil  or  vaseline,  and  insert  the  point  into 
the  urethra;  the  instrunient  at  this  moment  is  nearly  horizontal, 
the  concavity  of  the  curve  looking  towards  the  left  groin  of  the  pa- 
tient ;  the  instrument  should  be  slowly  carried  onwards  until  four  or 
five  inches  have  disappeared,  the  fingers  of  the  left  hand  gently 
drawing  the  penis  over  the  instrument  as  it  glides  easily  to  the 
bulbous  part ;  the  handle  should  meantime  gradually  approach  the 
median  line,  but  still  be  maintained  in  the  horizontal  position;  if 
there  is  any  obstruction  in  the  healthy  urethra  it  occurs  at  the  trian- 
gular ligament,  where  the  end  of  the  instrument  passes  along  the 
floor  of  the  bulb;  withdraw  the  catheter  half  an  inch,  and  elevate 
the  point  with  the  fingers  of  the  left  hand  in  the  perineum;  now  ele- 
vate the  handle  perpendicularly,  carry  it  steadily  over,  as  the  cath- 
eter passes  along  the  fixed  curve,  and  depress  the  handle  between 
the  thighs,  as  the  extremity  enters  the  bladder;  a  slight  rigor,  an  ex- 
pression of  distress,  the  freedom  of  the  point,  and  the  flow  of  urine 

1  S.  D.  Gross. 


THE   URINARY  BLADDER.  505 

prove  that  the  catheter  has  reached  its  destination.    In  removing  the 
catheter,  give  to  the  handle  the  same  curve  reversed. 

It  sometimes  happens  that  the  part  is  extremely  sensitive,  and  resists  any 
but  gentle  efforts  to  traverse  it,  the  more  so  if  it  be  the  first  time  an  instru- 
ment has  been  introduced  ;  the  involuntary  fibres  close  upon  it  as  if  to  repel  the 
intrusion,  and  the  perineal  muscles  are  prone  to  contract  on  the  approach  of 
the  unwonted  slinmlus;  some  persons  always  exhibit  this  involuntary  resistance, 
even  wiien  they  have  ijeconie  in  a  measure  Iiabituated  to  the  use  of  a  catheter; 
in  such  cases  no  violence  is  to  be  used,  as  any  attempt  to  force  a  passaj^e  would 
only  increase  the  dilliculty;  gentle  pressure,  steadily  maintained,  without  any 
poking  or  jerking  of  the  |)oiiit,  or  relaxing  of  the  hand  at  one  moment  anil  in- 
creasing its  power  at  another,  will  sooner  or  later  carry  the  instrument  through. i 

2.  The  sound,  a,  ft  (Fig.  499)  for  exploring  should  be  of  .«olid  metal, 
in  order  to  give  a  ck-ar  note  when  it  strikes  the  foi'eigii  body.  Its 
curved  part,  or  beak,  should  be  little  more  than  an  inch  long,  and 
have  more  of  a  tendency 
to  form  an  angle  with  the 
shaft  than  exists  in  the  calh 
eter;  it  may  be  hollow,  and 
thus  enable  the  operator  to  ^'*^-  ■*^^- 

inject  waicr  into  the  bladder,  or  withdraw  it,  without  change  of  in- 
struments.^ 

3.  The  endoscope  is  not  serviceable,  and  is  now  rarely  used  in 
the  examination  of  the  bladder  of  the  niale;^  it  has  a  limited  value 
in  examination  of  the  bladder  of  the  female. 

II.    MALFORMATION. 

Extroversion  of  the  bladder  ^  is  a  congenital  malformation,  oc- 
cin-ring  chiclly  in  males,  in  wliicli  the  anterior  j)ortion  and  the  parictes 
of  the  abdonu-n  are  ab.sent,  .so  that  the  posterior  and  lower  part  of 
the  bladdiT  protrudes  under  the  pressure  of  the  viscera  from  behind 
as  a  round,  red  tumor,  covered  by  mucous  membrane,  in  which  the 
orifice  of  the  ureters  can  be  seen. 

The  linea  alba  bifurcates  at  the  upper  angle,  but  is  continued  on  either 
side  of  the  ossa  pubis,  forming  a  triangle;  the  pubic  bones  are  not  united  bv  a 
symphysis;  the  penis  is  small,  the  urethra  and  corpus  spongiosum  are  deficient 
in  their  whole  extent,  and  the  only  remnant  of  the  urethra  is  a  groove  lined  by 
mucous  membrane  on  the  dorsum  of  the  penis;  the  glans  penis  is  full  and  large, 
and  the  prepuce  is  usually  of  fidl  size,  but  cleft  above.  In  the  female  there  is 
no  urethra  nor  clitoris,  but  the  mucous  surface  of  the  bladder  is  continued  di- 
rectly down  into  the  vagina. 

This  deformity  leads  to  painfid  and  distressing  results,  owin^  to 
the  constant  fhiw  of  urine  over  the  groin  and  thighs,  but  it  is  in  no 
1  Sir  H.  Thompson.  2  J.  \\,  g.  Gouley.  »  T.  Holmes. 


506 


OPERATIVE  SURGERY. 


respect  dangerous  to  life.  The  treatment  may  be  palliative,  by  the 
application  of  an  apparatus  to  collect  the  urine,  of  which  there  are 
many  kinds.  But  even  the  best  fitting  does  not  always  obviate  the 
gradual  soaking  by  urine  of  the  skin  of  the  abdomen,  groins,  and  per- 
ineum ;  and  hence  operations  have  been  devised  to  relieve  the  disgust- 
ing deformity.  I{;fforts  have  been  made  (1)  to  open  communication 
between  the  ureters  and  the  rectum,^  but  the  operation  is  very  dan- 
gerous, and  has  not  given  satisfactory  results;  2  (2)  to  cover  the  ex- 
posed surface ;  some  of  these  operations  have  been  very  successful, 
and  have  become  legitimate  by  the  approval  of  good  autliority. 

The  most  successful  opevatioiis  are  as  follows:  Make  an  umbilical  flap,  1  (Fig. 


Fig.  500. 


Vu:.  .jOl. 


500)3  and  turn  it  down  over  the  bladder;  then  make  two  flaps  from  the  groin, 
one  on  either  side,  2,  3  (Fig.  500),  and  slide  them  over  the  central  flap,  and  attach 

them  in  the  median  line  (Fig.  501);*  the 
result  is,  the  skin  surface  of  the  middle 
flap  presents  to  the  bladder,  and  the  raw 
surface  is  covered  by  the  raw  surfaces  of 
the  lateral  flaps;  the  new  wound  is  left 
to  cicatrize.  Or,  make  a  curvilinear  in- 
cision ^  (I'ig-  502)  from  the  outer  side  of 
Poupart's  ligament  4,  4  (Fig.  502)  down- 
wards below  the  scrotum  to  the  middle 
of  the  perineum,  and  thence  along  the 
opposite  side  to  a  point  corresponding 
with  the  first  incision;  dissect  up  this 
flap,  2,  to  the  root  of  the  penis,  3,  and 
make  a  valve-like  incision,  through  which 
now  make  one  transversely  across  the  abdomen,  1,  and  dis- 
sect up  a  trap-door  flap;  invert  the  lower  flap,  2,  so  as  to  bring  the  skin  sur- 
face in  contact  with  the  mucous  wall  of  the  i)ladder;  bevel  the  edges  of  the 
lower  flap,  and  bring  it  mider  the  trap-door  flap  by  means  of  the  tongue  and 
groove  suture,  5.6  Or,  dissect  off  the  mucous  membrane  of  the  exposed  blad- 
der;   make  lateral  flaps   from   both  inguinal  regions  (Figs.  503,  504);    unite 

1  J.  Simon.     2  p.  .lounlan.      3  Richards;  D.  Ayres;  J.  Wood.     *  j.  Wood. 
6  F.  F.  Maurv.     o  J.  i'ancoast. 


Fig, 

it  mav  be  drawn; 


502. 


THE   URINARY  BLADDER. 


507 


them  upon  the  median  line  and  transversely  above  it;  the  points  A,  A,  A,  and 
B,  B,  boiny  brougiit  togetlier,  as  the  skin  more  readily  yields  in  a  direction 
obliquely  upwards;  the  result  is  perfect  (Fig.  504 ).i 


^A// 


Vio.  503. 


Fig.  504. 


III.    INJURIES. 

1.  Rupture  of  the  bladder  may  be  caused  by  (I)  external  vio- 
lence, as  direct  blows,  oi-  falls,  or  crushing  injuries;  (2)  muscular 
efforts,  as  in  straining  to  pass  water  through  an  ol)structed  urethra, 
or  during  parturition;  (li)  thinning  or  ulceration  of  the  walls  of  the 
viscus. 

The  rupture  usually  occurs  when  the  organ  is  more  or  less  distended,  and  the 
rent  may  l)e  in  the  posterior  walls  covered  with  peritoneum,  the  contents  of  the 
organ  escaping  into  the  peritoneal  cavity,  or  in  the  anterior  walls,  the  extrava-. 
sation  taking  place  into  the  connective  tissue. 

The  symptoms  depend  upon  the  direction  which  the  urine  takes; 
if  it  escape  into  the  peritoneal  cavity,  there  is  generally  sudden  pain 
in  the  lower  abdomen  and  a  desire  to  void  urine;  this  effort  usually 
aggravates  the  pain  without  accomplishing  the  purpose,  though  some- 
times a  small  amount  of  water  tinged  with  blood  has  been  passed, 
and  even  with  considerable  force.  Shock  follows,  which  may  prove 
fatal,  but  usually  passes  off,  and  reaction  comes  on  with  high  fever, 
increased  pain  in  the  abdomen,  and  tympanitis;  the  desire  to  urinate 
diminishes,  uremic  poisoning  supervenes,  and  the  case  proves  fatal 
within  a  few  hours  to  four  or  five  days. 

If  the  extravasation  is  into  the  connective  tissue,  the  immediate  symptoms 
may  be  very  slight,  and  it  is  not  until  the  urine  has  j)enetrated  to  some  extent, 
and  its  corrosive  effects  are  felt,  that  tlioy  are  well  marked.    A  diffused  swelling 
1  U.  J.  Bigelow. 


508  OPERATIVE  SURGERY. 

appears  about  the  perineum  and  above  the  pubes;  a  low  form  of  fever  sets  in, 
with  typhoid  symptoms;  pain  is  not  much  comphiined  of;  the  swelling  extends 
in  the  subcutaneous  tissues  with  a  dusky  redness,  the  surface  is  oedematous,  the 
typhoid  symptoms  increase,  and  the  patient  dies,  poisoned  by  the  septic  matters. 
The  diagnosis  is  aided  by  the  introduction  of  the  catheter;  if  the  rent  is  into 
the  peritoneal  cavity,  the  catheter  passes  readily  into  the  bladder,  withdraws  a 
small  quantity  of  bloody  urine,  and  sometimes  can  be  carried  through  the  open- 
ing into  the  abdominal  cavity;  if  tiie  rent  is  in  the  anterior  wall,  a  larger  quan- 
tity of  urine  will  be  found  in  the  bladder;  if  the  urethra  is  torn,  the  catheter 
will  be  arrested  before  it  reaches  the  bladder. 

The  treatment  of  rupture  into  the  peritoneal  cavity  should  be,  in 
its  early  stage,  by  cystotomy,  for  the  purpose  of  affording  a  direct 
outlet  for  the  urine  as  it  enters  the  base  of  the  bladder.  The  method 
of  opening  the  bladder  should  be  that  of  lateral  lithotomy,  and  the 
external  wound  should  be  maintained  entirely  free  until  the  internal 
rent  is  closed.  Recovery  has  followed  the  timely  jierformance  of 
this  operation.! 

It  is  undoubtedly  of  immense  importance  to  remove  the  urine  from  the  peri- 
toneal cavity  and  cleanse  and  disinfect  it,  and  an  unsuccessful  attempt  has  been 
made  to  effect  this  object  by  incision  through  the  abdominal  walls,  closing  the 
rent  in  the  bladder  by  suture,  and  cleansing  the  cavity.2  It  would  seem  more 
rational  to  perform  cystotomy  first,  to  secure  free  escape  of  the  secreted  fluid, 
and  then  cleanse  the  cavity  by  incision  made  antiseptically;  or  to  cleanse  it  by 
repeated  injections  of  carbolized  fluids  and  aspiration  of  the  fluids  injected 
through  the  same  canula.** 

Tf  the  extravasation  is  through  the  anterior  wall,  the  swelling  will 
first  appear  above  the  pubes,  the  fluid  being  forced  in  that  direction 
by  the  deep  fascia.  Incisions  should  be  made  in  the  middle  line  of 
the  perineum  through  the  dee[)  fascia,  and  the  finger,  introduced  to 
the  bottom  of  the  wound,  should  gently  force  a  passage  towards  the 
■  suspected  point  of  ruj)ture,  for  the  purpose  of  opetiing  a  new  and  di- 
rect route  for  the  escape  of  the  urine ;  im-isions  should  also  be  made 
into  the  external  swelling  caused  by  the  infiltration  of  urine.  If  the 
water  readily  drains  away  by  catheter,  this  instrument  should  be 
retained  in  the  bladder. 

2.  Wounds  of  the  bladder,  by  puncture  or  incision,  are  very 
rare,*  but  shot  wounds  are  not  infrequent  in  military  practice. 
Though  dangerous,  the  latter  woiuids  are  by  no  means  fatal.^  The 
chief  points  which  demand  attention  in  the  treatment,  especially  of 
shot  wounds,  are  (1)  to  prevent  urinary  extravasation  into  the  neigh- 
boring parts;  (2)  to  subdue  inflammation;  (.3)  to  remove  foreign 
bodies,  especially  those  which  may  chance  to  lodge  in  the  cavity  of 
the  orgjin.^  If  the  wound  is  on  the  surface,  uncovered  by  the  peri- 
toneum, the  outflow  may  generally  be  effected  by  rest  in   the  best 

1  Walker:  E.  Mason.        2  a.  Willet.       3  j.  W.  S.  Gouley.       4  q.  A.  Otis. 
6  J.  A.  Lidell. 


THE  URINARY  BLADDER.  509 

position  for  drainaf^e  throu<rh  tlie  extfi-iial  wounds  and  through  the 
catheter  retained  in  the  blad(h'r,  the  catlieter  being  of  soft  rubber 
and  self-retaining;  if  these  means  do  not  sueeeed,  the  bhidth-r  must 
be  opened  at  its  most  depending  part  by  lateral  lithotomy;  if  the 
wound  is  through  the  peritoneal  surface,  cystotomy  is  immediately 
necessary.  The  resulting  inflammation  is  best  controlled  by  rest, 
and  opiates  in  doses  which  secure  perfect  quiet.  Foreign  bodies,  as 
cloth  an<l  balls,  may  often  be  removed  through  the  urethra;  if  bodies 
are  of  large  size,  or  angular,  the  bladder  should  be  opened  by  me- 
dian lithotomy. 

IV.    INFLAMMATIOX. 

The  painful  and  tedious  inflammations  of  the  bladder  have  their 
basis  in  a  peculiar  hypera?mia  of  the  mucous  membrane.  At  first 
they  are  excited  by  local  irritants,  or  obstructions  to  the  outflow  of 
the  urine,  but  subsequently  they  are  greatly  aggravated  by  the  action 
of  the  muscles.  This  is  diu'  to  that  pecidiar  arrangement  of  the 
arteries  and  veins  of  the  lining  membrane,  by  which  the  contraction 
of  the  muscles  does  not  affect  the  afflux  of  blooil  through  the  arteries, 
owing  to  tlieir  strong  connective-tissue  sheaths,  while  it  greatly  re- 
tards the  efflux  of  blood  through  the  veins  which  are  not  thus  pro- 
tected,^ and  hence  are  unduly  compressed.  As  a  result,  the  mucous 
membrane  becomes  so  loaded  with  blood  as  to  assume  a  dark  pur{)le 
color,  thickened  and  velvety,  in  some  cases  coated  with  adherent 
lymph  and  phosphatic  deposits  from  the  urine,  in  others,  ulcerated. ^ 

1.  Acute  cystitis  is  very  i-are,  and  usually  occurs  when  a  urethral 
inflammation  extends  to  its  neck,  or  some  injury  is  inflicted,  or  an 
irritant  enters  the  blachler,  as  a  rough  foreign  body,  or  a  chemical 
substance.  It  always  commences  on  the  mucous  surface;  the  irrita- 
tion produces  frequent  and  spasmodic  muscular  action,  which  leads 
to  muscular  hypertrophy,  a  constant  phenomenon  of  cystitis.  The 
symptoms  are  fever,  great  pain  in  passing  water,  frequency  of  mic- 
turition, bloody  in"ine  soon  becoming  purulent,  pain  and  tenderness 
on  pressure  in  the  region  of  the  bladder,  and  pain  t-xtemling  down 
the  thighs  and  perineum.  The  treatment  consists  (1)  in  the  removal 
of  the  exciting  cause,  if  that  can  be  determined,  and  of  every  pos- 
sible source  of  irritation;  for  this  purpose  the  patient  should  be 
kept  quiet  in  bed,  and  drink  freely  of  demulcent  fluids,  with  alka- 
lies, as  soda  or  j)Otash,  which  tend  to  dilute  the  urine  and  render  it 
unirritating,  if  very  acid;  (2)  tlie  local  hyperaemia  must  be  relieved 
by  leeches  to  the  perineum,  and,  in  very  severe  cases,  hot  hip-baths 
and  warm  fomentations  ;  (3)  the  muscular  spasm  must  be  controlled 
by  anodynes;  opium  by  the  rectum,  as  eneniata  or  suppositories,  is 
1  E.  Kindfleisch.  2  T.  Holmes. 


510 


OPERATIVE  SURGERY. 


invaluable;  or  hyoscyamus,  in  large  doses,  may  sometimes  be  prefer- 
able ;  or  morphia  injections  into  the  bladder. 

2.  Chronic  cystitis  ^  never  occurs  as  an  idiopathic  affection,  but 
invariably  arises  from  other  morbid  conditions  of  the  urinary  pas- 
sages, as  prostatic  and  urethral  diseases,  stone,  morbid  growths  in 
the  bladder  or  rectum,  decomposing  urine  retained  from  any  cause. 
The  symptoms  are  those  of  acute  cystitis,  modified  by  the  grade 
of  inflammation,  but  the  urir.^  always  contains  pus.  If  the  cause  is 
removed  and  the  symptoms  continue,  the  treatment  must  be  pallia- 
tive, namely,  suitable  hygienic  conditions,  and  the  injection  of  ano- 
dyne and  disinfectant  sokitions,  as  morphia,  with  carbolic  acid. 
One  of  the  most  important  features  in  this  treatment  is  irrigation 
of  the  inflamed  surface  with  weak  carbolic  solutions;^  this  may  be 
done  by  means  of  the  catheter  and  syringe,  the  best  syringe  being 
the  rubber  bag,  with  a  tapering  nozzle  and  stop-cock;  or  the  fountain 
syringe,  with  the  necessary  apparatus,  may  be  used  as  follows:  — 

To  the  fountain  syringe  bag  (Fig.  505)  holding  a  pint,  and  tube  of  variable 
length,   so   as   to   allow,  if   desirable,  consideralile  pressure  by  elevating  the 
bag,   is  attached  a  two-way  stop-cock  (Fig.  5U0);    upon   the  tube  is  another 
stop-cock  only  useful  when  it  is  desired,  having  thrown  a 
medicated  solution  into  the  bladder,  to  retain  it  there  for 
a  certain  length  of   time  without  either  allowing  to  be- 
come over  full,  or  its  contents  to  escape;  the  nozzle  of  the 
nickeled  stop-cock  is  very  large,  nearly  a  quarter  of  an 
inch  in  diameter,  and  tits  snugly  into  the  expanded  conical 
(also  nickeled)  mouth-piece;  it  is  so  large,  and  fits  so  eas- 
ih',  that  the  most  clumsy  tingers  can  readily  adjust  it  al- 
most unaided  by  sight;    upon  this  conical  catheter  mouth- 
piece is  fitted  a  thin  piece  of  rubber  tubing  covering  its 
upper  two  thirds;  this  allows  the  mouth-piece  to  be  used 
with  an}'  metallic  or  other  hard  catheter,  and  prevents  leak- 
age;   the  fine  conical  point  or  the   moutii-piece    is  to  be  ^^^'  ""^' 
screwed  into  any  soft  catheter  before  introducing  the  latter;  the  other  branch  of 


1  Van  Buren  and  Keves 


G.  Tiemann  &  Co. 


THE   URINARY  BLADDER.  511 

the  two  way  stop-cock  is  fitted  into  a  short  piece  of  niiibor  tiihing  which  con- 
veys tlie  urine  and  the  wasiiing  into  some  convenient  receptacle. 

In  obstinate  cases,  which  resist  all  treatment,  cystotomy  has  been 
performed  with  markeil  relief  to  the  siiiTering.* 

V.  KKTENTION  OF  UKINE. 
Inability  to  dischai-Lre  the  water  aeeumidating  in  the  bladder  results 
in  gradual  distention  of  the  organ;  the  cause  may  be  stricture  of  the 
urethra,  enlargement  of  the  prostate,  or  paralysis  of  the  muscular 
coats.  The  viscus  distended  appears  above  the  pubes  as  an  oval 
body,  distinctly  defined  to  the  touch,  and  gives  a  flat  percussion 
note;  the  finger  in  the  rectum  detects  a  globular  tumor  pressing  into 
the  lower  pelvis,  which  often  has  a  sense  of  fluctiuition  when  per- 
cussion is  made  externally.  If  the  cause  is  paralysis,  a  catheter 
must  be  frequently  passed,  and  the  bladder  should  be  washed  out 
with  slightly  carbulized  water.  If  obstruction  exists  which  cannot 
be  relieved,  the  bladder  must  be  punctured  The  aspirator  now  af- 
fords the  best  means  of  withdrawing  the  tiuid.  The  common  bulb 
syringe-  may  be  attached  to  the  large  aspirating  needle  and  the 
evacuation  readily  elleeted.  Enter  the  needle  just  above  the  pubes, 
first  making  a  slight  cut  through  the  integuments;  the  operation  may 
be  repeated  at  this  point  many  times  without  danger,  provided  the 
bladder  is  so  much  dilated  as  to  rise  well  above  the  pubes.  Punc- 
ture with  a  small  trocar  and  canula  may  be  made  at  the  same  point. 
Puncture  by  the  rectum  is  sometimes  resorted  to  as  follows:  Select 
a  small,  long,  curved  trocar  with  silver  canula:  after  the  action  of 
an  enema,  place  the  patient  on  the  back,  with  the  thighs  flexed; 
introduce  the  forefinger  of  the  left  hand  info  the  rectum,  until  the 
tip  rests  upon  the  posterior  part  of  the  prostate ;  carry  the  point  of 
the  trocar  behind  the  finger,  and  when  it  reaches  the  bladder  thrust 
its  point  forward  in  the  direction  of  the  centre  of  the  j)elvic  cavity; 
withdraw  the  trocar,  and  when  the  urine  has  all  escaped  insert  a 
cork  in  the  canula  and  retain  the  latter  by  a  bandage ;  if  the  blad- 
der cannot  be  distinguished,  puncture  should  not  be  made.* 

VI.  FOREIGN  BODIES. 
Substances  introduced  into  the  bladder  through  the  urethra  may 
be  of  every  variety  of  structure  and  consistency.  Whatever  may 
be  their  nature,  they  tend  to  form  nuclei  for  the  deposit  of  the  uri- 
nary salts,  and  either  by  themselves,  or  by  the  concretions  formed, 
become  sources  of  severe  irritation  of  the  bladder.  The  symptoms 
are  those  of  vesical  irritation  from  stone,  namely,  ])ain,  obstruction 
to  the  free  passage  of  urine,  and  evidences  of  cystitis.  The  pres- 
i  W.  Parker.  2  Davidson.  8  Van  Buren  and  Keyes- 


512  OPERATIVE  SURGERY. 

ence  of  a  foreign  body  may  be  acknowledged  by  tbe  patient,  or  dis- 
covered by  exploration  of  tbe  bladder.  If  tbe  foreign  body  is  dis- 
covered it  must  be  removed,  and  in  such  manner  as  to  create  tbe 
least  possible  injury  to  parts.  Tbe  most  serviceable  instrument  for 
general  use,  as  in  tbe  removal  of  a  portion  of  catbeter,  pin,  bead, 
slate-pencil,  small  stone,  is  tbe  litbotrite  (Fig.  507). ^ 

The  instrument  is  made  of  two  halves,  one  sliding  within  the  other,  and  is 
M)  ,n=r^  /^  If)   ^^  '''^  shape  of  an  or- 


dinarj'  catheter  when 
closed;     it    is    intro- 
FiG.  507.  diiced  into  the   blad- 

der by  the  urethra;  then,  by  means  of  a  screw  or  rack  and  pinion  worked  on 
the  outer  extremity,  the  movable  part  is  made  to  slide  back  witliin  the  bladder, 
now  forming  two  jaws,  by  which  the  body  is  seized;  by  turning  the  screw  or 
handle,  the  blade  is  propelled  onward,  and  the  substance  is  tirmly  held  and 
compressed,  if  possible,  so  as  to  admit  of  being  removed  readily  by  the  urethra. 

Introduce  it,  and  seize  the  body  witb  tbe  jaws  of  tbe  litbotrite, 
and  in  such  manner  as  will  present  its  long  axis  to  the  long  axis  of 
the  urethra.  The  exact  position  of  the  foreign  body  having  been 
determined,  place  the  beak  of  the  instrument  in  immediate  contact 
with  it;  now  open  the  jaws  by  turning  tbe  screw,  and  when  suffi- 
ciently separated  give  the  beak  a  slight  lateral  movement  and  turn 
the  screw  so  as  to  close  the  jaws;  if  the  object  is  seized,  tbe  position 
of  the  screw  will  indicate  its  size.  If,  on  attempting  its  withdrawal, 
the  body  cannot  be  engaged  in  the  urethra,  the  instrument  must  be 
loosened  and  the  body  seized  again  with  a  view  to  change  its  di- 
ameter. If  all  efforts  at  extraction  fail,  the  bladder  must  be  opened 
by  median  lithotomy,  and  the  body  removed. 

VII.  CALCULUS 
Vesical  stones  result  fi'om  the  accretion  of  the  salts  of  the  urine 
around  a  nucleus.  This  central  body  is  generally  sand  or  gravel 
which  descended  from  the  kidney;  but  it  may  be  any  insoluble  sub- 
stance forming  in  the  bladder,  as  mucus,  or  introduced  from  without, 
as  a  pin.  These  stones  vary  in  composition  according  to  the  constit- 
uents of  tbe  urine  in  each  case.  Two  sources  of  origin  are  recog- 
nized, namely:  (1)  from  the  organic  elements,  of  which  urea  and 
uric  acid  are  the  most  frequent;  and  (2)  from  the  inorganic  constit- 
uents, the  salts  of  the  urine,  of  Avhich  tbe  phosphates  are  most  im- 
portant.i  Tbe  symptoms  are  pain  at  the  neck  of  the  bladder,  along 
the  urethra,  and  under  the  glans  penis;  increased  frequency  of  de- 
sire to  void  urine,  with  spasmodic  pain  at  the  close  of  the  act;  blood 
in  the  urine  at  the  close  of  urination  or  after  severe  exercise;  sudden 
arrest  of  the  stream  of  urine  while  in  full  flow,  with  strong  spasmodic 
1  Sir  H.  Thompson.  2  A.  Poland. 


THE   URINARY  BLADDER.  513 

contractions  at  the  netk  of  tin-  bladtlcr  altended  by  severe  pain.' 
But  the  diaf^nosis  must  finally  rest  upon  the  detection  of  the  stone 
by  the  sound.  A  patient  suspected  of  liavin'^  a  stone  should  be  sub- 
jected to  a  course  of  treatment  preparatory  to  soundinj^.  such  as  rest, 
regulati(jn  of  the  bowels,  the  use  of  diluents,  tonics,  ;ind  nutritious 
diet;  the  first  exploration  should  be  matle  with  soft  bulbous  bou- 
gies, to  estimate  the  calibre  of  the  urethra  and  its  sensitiveness  ; 
the  second  examination  should  be  made  in  not  less  than  two  days 
with  a  searcher  of  abrupt  curve  and  short  beak  (Fijf.  507).2 

When  the  sound  enters  the  bladder  it  nnist  be  moved  to  and  fro,  to  the  right 
and  left,  and  then  reversed;  large  stones  usuall}-  lie  close  to  the  vesical  neck, 
and  are  readily  felt,  but  niediiun  and  small-sized  calculi  are  more  apt  to  be  found 
in  the  posterior  part  of  the  bas-fond  on  either  side  of  the  median  line  ;  the  con- 
tact of  the  instrument  with  a  calculus  will  determine  by  the  note  whether  it  is 
hard,  soft,  or  encysted. ^ 

The  various  operations  for  the  removal  of  stone  from  the  bladder 
are  arrani,aMl  under  two  hea<ls,  namely,  lithotrity,  by  which  tlie 
stone  is  crushed  in  the  bladder  and  removed  throujrh  the  natural 
passages  without  cuttiu'^;  and  lithotomy,  by  which  the  stone  is  re- 
moved through  an  artificial  opening  made  into  the  urethra  or  blad- 
der.' Very  marked  differences  of  opinion  exist  as  to  the  relative 
merits  of  the  several  operations  embraced  under  these  two  heads. 
The  special  adaptation  of  each  operation  will  be  specified  so  far  as 
it  has  been  determined. 

The  management  of  vesical  stones  strikingly  illustrates  the  truth  previously 
emphasized,  that  good  judgment  is  quite  as  important  as  operative  skill ;  but  to 
attain  the  best  success  the  two  shoukl  go  hand  iu  hand.  There  is  no  exclusively 
best  method  of  dealing  with  these  foreign  bodies,  and  there  is  no  particular 
method  applicable  to  all  cases  even  of  a  kind,  for  experience  teaches  that  one 
patient  will  bear  immediate  surgical  operation,  be  it  lithotomy  or  lithotripsy, 
while  another  of  the  same  age,  and  apparently  in  the  same  state,  will  l)e  killed 
by  preciselv  the  same  treatment;  the  judicious  surgeon,  therefore,  will  select 
from  among  the  many  known  operative  procedures  the  one  which  is  indicated 
after  due  consideration  ancl  study  of  all  the  peculiarities  of  the  individual  case.- 

1.  Ordinary  lithotrity  aims  first  at  reducing  the  stone  to  a  con- 
dition ill  which  it  will  lunst  injure  the  mucous  membrane  an<l  be  most 
readily  expelled  from  the  bladder,  namely,  that  of  powder;  and, 
second,  to  effect  this  object  by  the  smallest  amount  of  instrumental 
interference.*  It  is  especially  indicated  when  the  general  condition 
of  the  patient  is  ijood,  the  urethra  capacious,  the  bladder  tolerant  of 
instruments,  and  the  stone  is  found  of  medium  or  small  size  and  soft; 
it  may  be  applied  to  children  when  the  stone  can  be  destroyed  at 
one  or  two  sittings,  and  is  very  successful  in  old  men  with  enlarged 
prostates. - 
1  Van  Buren  and  Keves.  ^  j.  \w  g.  Gouley.  3  gji-  n.  Thompson. 

33 


dU 


OPERA  TI VE  S  UR  GER  Y. 


The  principal  evils  arising  from  the  practice  are  traceable  to  the  intlammation 
of  the  bladder  and  urethra,  almost  invariably  caused  either  by  instrumental  ex- 
amination, or  the  presence  of  sharp  or  angular  fragments;  the  aim  of  the  opera- 
tor, therefore,  should  be  to  reduce  the  stone  to  a  condition  in  which  it  will  least 
injure  the  mucous  membrane,  and  be  most  readily  expelled  from  the  bladder  with 
the  smallest  possible  amount  of  instrumental  interference;  these  principles  are 
to  be  constantly  kept  in  view  in  the  selection  of  instruments,  and  in  the  numer- 
ous details  connected  with  the  operation  i 

The  lithotrite  should  be  so  constructed  that  it  will  not  become  im- 
pacted, will  have  adequate  power,  and  will  be  of  easy  manipulation. 
These  features  are  now  combined  in  an  instrument  (Fig.  508)^  con- 

structeil  as  follows  :  the 
floor  of  the  female  blade 
f,  is  raised,  and  lateral 
notches  added  to  the 
male  blade,  e,  which  is 
also    jjrovided    with    a 


Fk;.  508.-5 


central  septum  at  the  heel;  the  lateral  grooves  for  the  male  blade 
extend  through  the  heel  of  the  female  blade;  the  movement  for  lock- 
ing a  lithotrite  is  by  a  quarter  rotation  of  the  bulb,  a,  without  dis- 
placing the  fingers  of  either  hand;  as  the  rapidity  of  a  lithotiite 
depends  upon  the  inclination  of  its  screw  thread,  and  as  the  slowest 
screw  gives  most  power  and  requires  the  strongest  blades,  in  the 
longer  and  more  rapid  operation,  larger  and  stronger  blades  than 
have  been  comuionlv  employed,  and  which  also  better  protect  the 
bladder  than  do  the  latter,  are  desirable. 

The  blades  of  a  lithotrite  should  be  as  nearly  at  right  angles  with  the  shaft, 
and  their  floor  as  straight,  as  is  compatible  with  their  convenient  introduction 
into  the  bladder;  many  instruments  are  made  with  an  oblique  blade,  which  is 
also  so  rounded  at  the  heel  as  to  curve  their  floor ;  this  is  a  mistake  ;  a  cubical 
stone,  for  instance,  would  exactly  fit  a  right-angled  lithotrite;  but  when  the 
.same  blades  are  made  oblique,  at  an  angle,  for  example,  of  forty-five  degrees 
with  the  shaft,  then,  in  order  to  grasp  the  same  stone,  they  must  not  only  be 
opened  wider,  but  they  will  touch  the  stone  at  points  nearer  the  shaft  than  be- 
fore, for  the  size  of  their  grasp  rapidly  diminishes  with  their  obliquity ;  they 
must  be  opened  wider,  and  they  seize  less  of  the  stone;  their  power  also  dimin- 
ishes, because,  if  they  are  made  longer  with  the  view  of  retaining  the  size  of 
their  grasp,  their  increasing  leverage  increases  friction  in  the  slide  ;  this  is 
readily  seen  by  increasing  their  obliquity  until  they  reach  the  line  of  the  stem 
of  the  instrument,  when  they  tend  merely  to  roll  the  fragment  between  them; 

1  Sir  H.  Thompson.  2  h.  J.  Bigelow.  3  g.  Tiemann  &  Co. 


THE   URINARY  BLADDER.  515 

the  latter  then  acts  only  as  a  wedge  to  separate  fheni,  and  the  friction  of  the 
slide  is  then  greatest;  in  otiier  words,  right-angled  blades  crush  best  and  wedge 
least;  obli(iiie  blades,  on  the  contrary,  wedge  more  and  crush  less,  while  the 
depth  of  thfir  grasp  is  also  less;  and  what  is  here  true  of  the  whole  blade  is  true 
of  any  part  of  it  —  the  heel,  for  exani|)le,  which  should  not  be  oblique  nor  much 
rounded,  but  as  nearly  at  right  angles  wiih  the  shaft  and  with  as  straight  a 
floor  as  is  compatible  with  its  convenient  introduction.!  The  tip  of  the  female 
blade  should  be  beveled,  so  that  (if  com)i:ired  to  a  bent  finger)  it  niav  impinge 
against  the  upper  wall  of  the  prostate,  while  passing  it,  rather  witli  its  pulp 
than  with  its  nuil.i 

Before  the  operation  efforts  should  be  made  to  alia}'  any  existintr 
irritation  of  the  bladder  by  rest  and  anodynes,  continued  for  several 
days.  At  the  moment  of  operation  the  bladder  should  contain  a 
moderate  amount  of  water,  either  retained  or  injected.  An  anaes- 
thetic is  not  required  in  the  ordinary  operation. 

In  passing  the  lithotrite,i  the  continuous  sweep  of  the  catheter  will  not  be 
successful  in  carrying  it  into  the  bladder,  as  the  terminal  angular  part  consti- 
tuted by  the  blades  would  thus  impinge  upon  the  anterior  wall.  It  may  happen 
that  the  meatus  will  not  admit  the  instrument,  when  it  must  be  incised  in  the 
direction  of  the  fra-num. 

Introducing  the  point  of  the  beak  into  the  urethra,^  the  instrument 
and  penis  being  held  as  in  cathcterisni,  carry  it  down  to  the  triangu- 
lar ligament;  having  reached  this  point,  withdraw  it  slightly,  and 
make  traction  on  the  penis  to  efface  the  depression  of  the  floor  of 
the  urethra  made  by  the  end  of  the  instrument;  now  guided  by  the 
bony  arch  above,  pass  the  point  through  the  ligament;  the  rest  of 
the  canal  corresponds  with  the  axis  of  the  body  and  is. generally 
easily  traversed,  tbe  instrument  being  pressed  throu'j;h  the  indurated 
neck,  or  prostate,  in  the  direction  of  the  axis  of  the  bod)-,  with  the 
hand  on  the  perineum,  when  the  prostate  is  large;  if  there  is  doubt, 
the  tip  may  be  guided  by  the  finger  in  the  rectum ;  the  straight 
tube,  or  the  shaft  of  a  curved  one,  now  returns  to  an  angle  of  about 
45°  with  the  recumbent  body.  When  in  the  bladder,  the  lithotrite 
should  first  be  used  as  a  sound,  the  blades  being  closed;  pass  the 
extremity  from  point  to  point,  over  the  internal  area,  systematically 
exploring  one  region  after  another,  in  orderly  succession,  until  the 
object  is  found,  or  the  entire  area  of  the  bladder  has  been  thoroughly 
examined. 

In  this  exploration  the  instrument  should  not  only  be  lightly  thrust  forward 
at  every  point,  in  order  to  strike  with  some  force  the  object,  but  also  turned 
rapidly  with  the  fingers  on  its  own  axis  from  side  to  side,  to  enable  the  beak  to 
detect  anything  situated  laterally. 

When  the  stone  is  felt,  a  slight  lateral  movement  of  the  blades 
determines  on  which  side  it  lies;  incline  the  blades  away  from  it  and 
1  H.  J.  Bigelow. 


516 


OPERA  TI VE  S UR  GE R Y. 


pass  them  towards  the  posterior  wall,  while  the  male  blade  is  unlocked 
and  withdrawn;  then  incline  the  blades  towards  the  stone  and  slowly 
close  thoni  upon  it  (Fig.  509). ^     Or,  the  blades  may  be  passed  to 

the  most  dej)ending 
part  of  the  bladder 
(Fig.  510),  and  the 
niale  blade  withdrawn 
with  a  view  to  enable 
the  stone  to  fall  be- 

' ('/Kll  )  //////  A'y^<^  tween  them;  this  ob- 

ject may  be  effected 
sometimes  by  a  slight 
Fig.  509.  jar  of  the   handle  by 

tapping  with  the  fingers.^  The  stone  having  been  seized,  the  screw 
must  be  slowly  turned  until  the  grasp  is  firm;  with  the  common  litlio- 
trite  there  is  danger  of  seizing  the  mucous  membrane,  and  such 
movements  of  the  blade  should  be  made  as  will  prove  that  the  instru- 
ment is  free;  grasping  the  handle 
firmly  with  the  left  hand,  turn 
the  screw  with  the  right,  until 
the  stone  breaks;  withdraw  the 
male  blade,  and  without  moving 
the  instrument,  again  close  them 
upon  such  fragments  as  fall  be- 
tween them ;  this  act  may  be 
repeated  several  times,  when  the 
instrument  must  be  withdrawn. 
The  patient  must  be  placed  in 
bed  and  warmly  covered,  and 
five  grains  of  quinine  administered.  The  detritus  must  be  allowed 
to  escape  with  the  urine,  no  efforts  being  made  to  remove  it.  The 
operation  should  not  be  repeated  for  three  or  four  days,  according 
to  the  condition  of  the  patient. 

The  following  practical  maxims  3  should  be  observed:  (1)  execute  every 
movement  deliberately;  open  and  close,  incline,  or  rotate,  slowly,  without  any 
jerk  whatever,  and  without  bringing  the  blades, as  far  as  possible,  in  contact 
with  the  walls  of  the  bladder;  (2)  take  care  that  the  blades  reach  or  pass  be- 
5'ond  the  centre  of  the  bladder  before  the  male  blade  is  withdrawn;  (-3)  main- 
tain the  long  axis  of  the  instrument  in  the  median  line  of  the  bod}'  and  the 
blades  at  or  near  the  centre  of  the  bladder,  this  being  the  area  for  operating 
mostly  to  be  chosen;  in  screwing  home  the  male  blade  to  crush  it  is  especially 
necessary  to  keep  the  instrument  steady,  for  a  small  deviation  of  the  handles 
produces  a  large  one  at  the  blades;  (4)  when  the  stone  is  caught,  especially'  in 
the  fenestrated  lithotrite,  rotate  it  a  fourth  of  a  turn  on  its  axis  before  crushing 


Fig.  510. 


1  M.  Civiale. 


2  B.  C.  Brodie. 


3  Sir  H.  Thompson. 


THE   URINARY  BLADDER. 


ol7 


to  make  cprtain  that  nothinf;  is  included  besides  the  stone;  (5)  havinff  hroken 
the  stone,  the  fraf,niieiits  fall  immediately  beneath  the  instrument,  where  tliey 
may  be  seized  without  searchini;,  and  crushed,  if  the  instrument  is  carefully 
■worked,  exactly  in  the  same  spot,  the  patient  not  moving;  (<i)  never  withdraw 
the  lithotrite  loaded  with  calculous  (h-bris  ;  (7)  the  larj^e  majority  of  sittings 
should  occupy  but  three  minutes,  and  no  sittiiif?  should  exceed  live  minutes, 
except  under  pecidiar  circumstances;  (8)  after  the  tirst  sitting,'  it  is  Kenerallv  de- 
siral)le  that  the  patient  should  have  hot  fomentations  to  the  hypopistrium  and 
perineum,  remain  in  bed,  and  pass  his  water  in  the  recumbent  position,  until 
the  debris  has  passed,  which  usually  requires  three  days. 

2.  Litholapaxy  ^  is  the  immediate  removal  of  the  deliris  created 
by  the  lithotiite ;  this  operation  is  advocated  on  the  ground  that 
when  the  operation  is  prolonged  through  several  sittings,  the  stone 
being  broken  into  fragments,  which 
could  be  only  in  part  removed 
through  the  imperfect  evacuating 
apparatus  employed,  the  subse- 
quent vesical  irritation  is  more 
largely  due  to  these  fragments  than 
to  the  instrument ;  hence  the  ne- 
cessity of  crushing  the  stone,  pul- 
veriznig  its  fragments,  and  Avith 
an  eflicient  evacuating  apparatus 
removing  the  fragments  and  the  de-  ^ 
tritus  at  a  single  operation,  though  f^ 
it  may  be  indefinitely  i)rolonged.      ^ 

Rapid  lithotrity  has  thus  far  given  a 
larger  mortality  than  the  old  method, 
being  ten  per  cent,  of  the  former,!  to 
eiglit  per  cent,  of  the  latter.'-^  It  will, 
therefore,  be  prudent  to  discriminate 
in  deciding  to  adopt  this  method.  It 
seems  best  adapted  to  those  cases  of 
lithotrity  which  have  very  large  nreth- 
rse,  a  slight  amount  of  vesical  irrita- 
tion, and  no  organic  disease  of  the  kid- 
ney. 

The  important  instrument  required 
in  this  operation  is  an  eflicient  evacu- 
ating apparatus.  This  consists  of  the 
following  parts:  (1)  an  elastic  bulb; 
(2)  a  rubber  tube  two  feet  in  leni^th  ; 
(3,  4,  b)  evaciuiling  silver  tubes  of  large 
calibre,    straight  or  curved  quite   near 


--^ 


Fig.  511. 


the  extremity;  (G)  glass  receptacle.  The  calibre  of  the  evacuating  tube  should 
be  23  to  .31,  or  even  32  French  scale,  for  upon  its  size  depencls  its  efHciency. 
The  receiving  extremity  should  depress  the  bladder,  and  thus  invite  the  frag- 

1  II.  J.  IJigelow.  2  Sir  U,  Thompson. 


518 


OPERATIVE  SURGERY. 


nients,  while  its  orifice  remains  unobstrucfed  by  the  mucous  membrane;  the 
best  orifice  is  at  tiie  side  of  the  extremity,  and  is  made  by  bending  the  tube  at 
a  sharp  angle,  rounding  the  elbow,  and  cutting  off  the  bent  branch  close  to  the 
straight  tube;  the  tube  is  then  practically  straight,  while  its  orifice  delivers  a 
stream  at  an  angle.  The  obstructions  of  the  tube  are  readily  recognized  by 
watching  the  expanding  of  the  rubber  bottle  with  a  dimple  in  its  side;  if  this 
remains  stationary'  for  a  moment,  a  fragment  fills  the  orifice,  and  must  be  ex- 
pelled by  compressing  the  bulb. 

The  operation  is  performed  as  follows :  ^  Place  the  patient  on  a  firm 
table  and  give  ether ;  inject  eight  to  ten  ounces  of  warm 
water  into  the  bladder,  or  sufficient  to  render  the  walls 
moderately  tense,  the  capacity  of  the  organ  having  been 
previously  determined;  introduce  the  lithotrite,  and  wind 
a  tape  or  elastic  band  around  the  penis  to  retard  the  es- 
cape of  the  water,  and  if  too  much  escape  inject  more 
through  the  lithotrite  ;  seize  and  crush  the  stone,  and 
repeatedly  crush  the  fragments;  withdraw  the  lithotrite, 
and  introduce  the  tube  of  the  evacuating  apparatus,  the 
proper  amount  of  water  being  luaintained;  press  the  point 
gently  to  the  base  of  the  bladder,  and  if  the  elastic  bulb 
is  compressed  release  the  grasp  and  allow  it  to  dilate;  a 
quantity  of  detritus  falls  to  the  bottom  of  the  glass  recep- 
tacle ;  when  the  bulb  is  dilated,  repeat  the  manoeuvre, 
forcing  the  water  slowly  into  the  bladder,  and  again  re- 
leasing the  grasp  and  allowing  suction  to  be  applied;  if 
at  any  time  the  bulb  cease  to  expand,  a  large  fragment 
has  entered  the  tube,  and  must  be  expelled  by  forcing 
the  water  out.  If  large  fragments  remain,  the  lithotrite  is 
again  introduced,  the  fragment  crushed,  and  the  evacuat- 
ing catlieter  again  employed.  The  single  sitting  has  been 
prolonged  from  an  hour  to  three  and  three  quarters  hours. 
The  subsequent  treatment  is  the  same  as  the  ordinary 
method. 

3.  Perineal  lithotrity  ^  is  based  on  the  extreme  dila- 
tability  of  the  vesical  neck  without  injury,  and  is  adapted 
to  large  calculi  in  an  irritable  bladder,  conditions  unfavor- 
able to  lithotrity   and  lithotomy.     It  consists  in  opening 
the  urethra  by  perineal  incisions,  dilatation  of  the  neck  of 
the  bladder,  crushing  of  the  stone  by  forceps,  and  its  im- 
mediate removal. 
The  special  instruments  required  are  a  strong,  straight,  lancet- 
§!liS\      pointed  bistoury,  a  six  branched   prostatic  dilator,   three  or  four 
Fig.  512.    lithoclasts  of  different  shapes  and  strength,  two  or  three  pairs  of 
small  straight  and  curved   forceps,   a  scoop,   and  a  long-nozzled 

1  H.  J.  Bigelow.  "^  Dolbeau, 


THE   URINARY  BLADDER. 


519 


rubber  syringe.  The  dilator  (Fi{^  512)  is  composed  of  six  uniform  metallic 
branches  held  tofjetlier  by  an  India-rubber  band;  the  vesical  end  is  conical,  and 
surmoinited  by  a  small  metallic  hood  which 
covers  the  free  extremities  of  the  six  branch- 
es, and  fits  in  the  groove  of  the  staff;  in  the 
centre  of  the  branches  are  two  spheres  at- 
tached to  a  stem  which  extends  (rom  the 
hood  at  the  vesical  extremity  to  terminate 
by  a  screw-thread  in  the  handle;  when  the 
handle  is  turned  the  spheres  are  pushed  for-       M    ^\l \\<i 


Fig.  513. 


a  powi 


ward  from  their  con- 
cealed position,  and 
the  instnnnent  is 
gradually  developed. l 

The  operation   is  as  follows:'    the   patient,  properly 
prepared,  is  etherized  and  placed  in  the  litlioloni}'  posi- 
tion: the  staff  is  held  in  position  by  an  assistant;  an  in- 
cision a  little  less  than  an  inch  is! 
made  in  the  median  line,  extend- 
ing to  the  anal  margin,  the  skin, 
superficial  and  deep   fascia,  being 
divided,  the  left  index  linger  nail 
is  pressed  into   the  groove   of  the  staff,  and 
the  membranous  portion  punctured  wiih  the 
knife,  the  bulb  and  rectum  being  avoided ; 
the  urethra  is  incised  about  one  fourth  of  an 
inch,  and  the  extremity  of  the  dilator  intro- 
duced along  the  groove  of  the  staff  (Fig-  513), 
and  methodical  divulsion  of  the  urethra  be- 
gun ;  by  this  effort,  the  external  wound  and 
urethra  are  so  enlarged  that  the  closed  instru- 
ment enters  the  prostatic  portion,   which  is 
slowly  dilated  while  the  handle  is  depressed 
130^  to  carry   the   point    nearer   the  vesical 
neck ;    file   dilator   is   again    closed   and   ad- 
vanced,   the   staff"    removed,    and    dilatation 
again  slowly  made;  in  this  third  step  the  in- 
troduction  and  opening  of  the  dilator  must 
be  very  slow,  no  violence  being  used,  and 
when   there   is  great   resistance   the   process 
should  stop  for  a  moment,  and  then  be  slowly 
repeated,    until   the  vesical  neck  admits  the 
dilator  ;  the  instrument  should  be  withdrawn 
open.    The  reduction  of  the  stone,  lithoeIa>ty,  ^       ti-  2 
is  now  practiced.     The  lithodast  (Fig.  514)  is 
of  small  diameter  when  closed,  and  admitting  of  opening 


1  J.  W.  S.  GOULEY. 


2  G.  Tiemann  &  Co. 


520 


OPERA TI VE  SUR GER Y. 


of  the  beaks  without  increasing  the  shaft,  anfl  in  its  improved  form,  with  curved 
beaks,  to  admit  of  seizing  stones  behind  the  pubes.i     The  extraction  of  frag- 
ments is  made  witli  the  litlioclast  and  scoop.    The 
after-treatment  is  the  same  as  for  litliotrity. 

4.  Median  lithotomy  ^  is  eminently 
applicable  for  small  stones  in  a  bladder 
which  will  not  tolerate  the  use  of  instruments  without 
chill  or  other  disturbance;  for  multiple  small  stones  in  the 
adult;  and  for  boys  too  young  for  litliotrity  .^  The  instru- 
ments required  are  a  staff,  director,  and  knife.  The  staff 
has  a  broad,  deep  groove  (Fig.  615);*  but  there  are  ad- 
vantao'es  in  having  a  larger  curve  and  deeper  groo\e  (Fig. 
516).^  A  director  (Fig.  51 7)^  six  inches  long,  with  a  flat, 
tapering  groove  and  probe  point,  is  very  desirable  to  pass 
along  the  staff,  after  the  knife  is  wiihilrawn,  as  a  guide 
to  the  finger.  The  operation  is  as  follows:  The  patient 
being  properly  placed  and  etherized,  and  the  staff  in  the 
hand  of  an  assistant,  introduce  the  left  index  finger  into 
the  rectum,  and  place  its  extremity  in  contact  with  the 
staff  so  as  to  steady  it;  with  the  knife,  pierce  the  peri- 
neum in  the  middle  line  about  half  an  inch  above  the 
anus,  or  at  such  distance  as  will  clear  the  fibres  of  the 
external  sphincters  (Fig.  518);  carry  the  knife  steadily 
and  firmly  on  till  it  strikes  the  groove  of  the  staff;  now 
move  the  jioint  of  the  knife  along  the  groove  a  few  lines  Fig.  516.6 
towards  the  bladder,  and  then  withdraw  it,  cutting  upwards, ^  so  as 
to  leave  an  external  incision  of  from  three  quarters  of  an  inch  to  one 
inch  and  a  half,  according  to  the  size  of  the  stone  ;  introduce  the  di- 
rector (Fig.  517)  along  the  groove  well  into  the  bladder,  and  remove 
the  staff;  pass  the  index  finger  of  the  left  hand,  well  oiled,  along 


Fig.  517.6 


the  director,  with  a  semi-rotary  motion,  through  the  prostate  into  the 
bladder;  when  the  stone  is  free,  it  comes  in  contact  at  once  with  the 
finger,  and  passes  into  the  wound  on  withdrawing  the  finger;  the 
patient  makes  powerful  expulsive  efforts,  which  keep  the  stone  in 
contact  with  the  wound,  Avhere  it  may  be  seized  with  forceps;  if  the 
stone  is  larger  than  the  finger,  the  opening  must  be  dilated,  or  the 


1  J.  W.  S.  Goi;ley. 
4  T.  M.  Maikoe. 


2  G.  Alhu-ton. 
6  J.  L.  Little. 


3  Van  Biiren  and  Keyes. 
6  G.  Tiemaan  &  Co. 


THE   URINARY  BLADDER. 


5?1 


stone  maj^  be  seized  with  a  lifliotrite  and  crushed;  or,  if  very  large, 
the  wound  may  lie  cnlarfreil  by  vertieal  or  lateral  incisions. 

5.  Medio-lateral  lithotomy  was  devised  ^  on  account  of  the  dan- 
gers of  lateral  lilbut- 
omy  ;    the    membra-  .^=^'^-?-'t 

nous   portion   of    the  ^^ 

urethra  was  opened 
upon  an  anii;idar  staff", 
and  the  prostate  was 
divide<llaterally.  The 
following  nietboil  ^  is 
more  easily  executed, 
and  is  in  other  re- 
spects preferable  :  * 
The  patient  placed  in 
the  ordinary  position 
for  lithotomy,  the  staff 
in  position,  an  incis- 
ion is  made  in  the  Fig.  518. 
median  line  of  the  perineum,  from  before  backwards,  and  terminating 
two  or  three  lines  in  front  of  the  anus ;  from  this  point  the  incision  is 
continued  for  a  quarter  of  a  circle  around  the  left  side  of  the  rectum; 
the  rectum  is  pressed  back  with  the  finger  of  the  left  hand  aided  liy 
the  knife;  the  left  index  finger  is  now  passed  into  the  rectum,  and 
the  knife,  with  its  back  towards  the  bowel,  is  passed  at  the  posterior 
part  of  the  central  incision  into  the  membranous  portion  of  the 
urethra;  the  incision  of  the  prostate  is  made  from  within  outwanls; 
in  chihlren,  a  single  incision  is  sufficient,  but  in  adults  the  circular 
part  of  the  wound  should  be  deepened  before  or  after  the  urethra  is 
oj)ened:  the  forceps  are  now  introduced,  and  the  stone  removed. 

G.  Bilateral  lithotomy  *  consists  of  a  transverse  incision  of  the 
perineum  and  prostate  to  an  ecpial  extent  on  either  side  of  the  me- 
dian line.  The  advantages  claimed  are  ^  simplicity  of  operation; 
more  direct  access  to  the  bladder;  extent  of  wound  admitting  e.x- 
traction  of  large  calculi  without  unduly  dividing  the  prostate.  The 
special  instnunent  required  is  a  bisector,  with  a  properly  grooved 
staff"  (l"ig.  519).  Operate  as  follows:  ^  The  patient  beiu'j:  in  the 
lithotomy  position,  and  the  staff  held  in  the  vertical  ilirection  by  an 
assistant,  make  a  semi-lunar  incision,  convex  upward,  from  a  point 
midway  between  the  anus  and  ischium  of  the  right  to  a  correspoml- 
ing  point  on  the  left  side,  passing  about  half  an  inch  anterior  to  the 
anus,  1  (Fig.  518);  the  dissection  is  continued,  until  the  nail  of  the  left 


^  nucliaiiMii. 
fi  J.  li.  Wood. 


2  II.  Lee. 


3  J.  W.  S.  GotLKY. 


•»  Dupiiytrcn. 


522 


OPERATIVE  SURGERY. 


index  is  placed  in  the  groove  of  the  staff  in  the  membranous  por- 
tion of  tlie  urethra;  the  urethra  being  opened,  the  knob  of  the  bisec- 
tor is  phiced  in  the  groove  of  tlae  staff  (Fig.  519);  tlie  staff  being 


Fig.  519.1 


depressed  by  the  operator,  the  bisector  is  pushed  through  the  pros- 
tate bisecting  it;  tlie  finger  is  now  passed  along  the  staff  into  the 
bladder,  the  staff  removed,  and  the  forceps  passed  along  the  finger. 
7.  Lateral  lithotomy  '^  is  so  named  from  the  lateral  incision  of 
the  prostate  gland  and  neck  of  the  bladder. ^  This  method  is  un- 
doubtedly best  in  children,  as  the  incis- 
ion is  not  liable  to  injure  the  seminal 
ducts,  a  free  outlet  is  affoT'ded  for  the 
extraction  of  the  stone,  and  there  is  lit- 
tle danger  of  peritonitis  from  violence, 
even  with  large  stones;  in  the  adult  it 
is  to  be  preferred  for  the  removal  of 
large  stones,  and  where  the  stone  is 
small  or  large  when  the  bladder  is  more 
than  ordinarily  irritable  and  inflamed.* 
The  instruments  required  are  as  fol- 
lows: the  scalpel  (Fig.  520),  a  grooved 
staff  (Fig.  521),  a  straight  or  beakeil  bis- 
toury ^  (Fig.  522)  or  lithotoine,®  straight 
and  curved  forceps  (Figs.  523  and  5'24), 
the  scoop  (Fig.  525)  for  the  removal  of 
fragments  and  as  a  conductor  for  the 
y  forceps  in  deep  wounds. 

Operate  as  follows  : ''  Every  care  be- 
ing taken  that  the  patient  is  in  favorable  condition,  the  perineum 
should  be  shaved, an  enemaof  warm  water  administered  about  an  hour 


Fig.  520.1      Y\g.  521. 


Ill 
Fig. 
522. 


1  G.  Tiemami  &  Co. 
5  W.  Blizard. 


2  Franco, 
c  Bri-ffs. 


3   S.  Cooper.     4  Van  Buren  and  Kej'es. 
"!  Sir  W.  Ferffusson. 


THE   URINARY  BLADDER. 


523 


before,  and  after  its  action  the  urine  should,  if  possible,  be  retained 
until  the  operation  ;  place  the  patient,  etherized,  on  the  operating 
table,  and  introduce  the  stalT,  which  shoidd 
be  as  large  as  the  urethra  will  admit  with 
ease,  and  of  such  a  shape  as  that  deliu- 
eate<l,  having  the  groove  presenting  a  liitle 
to  the  left  side  of  the  urethra;  the  instru- 
ment should,  if  possible,  be  made  to  strike 
the  stone,  and  should  then  be  given  in 
charge  of  an  assistant;  the  hips  should  be 
brought  to  the  margin  of  the  table,  the 
staff  held  nearly  perpendicular,  with  the 
concavity  of  the  curve  resting  on  the  up[)er 
part  of  the  triangular  ligament,  right  side; 
sit  in  front  of  the  perineum,  having  pre- 
viously arranged  with  an  assistant  about 
having  the  instruments  handed,  or  havinnf 
already  assorted  them  i)roperly  on  a  chair;  pass  the 
forefinger  of  the  left  hand,  well  oiled,  into  the  rectum,  to 
ascertain  the  size  of  the  prostate,  and  the  depth  of  this 
organ  from  the  surface  ;  trace  the  course  of  the  ramus 
of  the  pubes  and  ischium  on  the  left  side,  ascertain  the 
position  of  the  tuberosity  of  the  latter  bone  on  each  side, 
and  liaving  scanned  the  whole  surface,  proceed  to  use  the  knife,  srasp- 
ing  it  much  in  the  manner  of  a  common  bistoury,  but  with  the  hand 
and  instrument  pointed  directly  to  the  perineum;  enter  the  point  about 
one  inch  and  three  fourths  in  front  of  the  anus,  2  (Fig.  518),  a  line's 
breadth  left  of  the  raphe,  push  through  the  skin,  and  carry  it  by  a 
kind  of  sawing  motion  down  the  left  side  of  the  perineum,  about  an 


Fig.  5-2.3. 


Fig.  524. 


Fig.  525.1 


inch  beyond  the  anus,  3  (Fig.  518),  the  middle  of  the  incision  being 
at  equal  distances  from  the  latter  part  and  the  tuberosity  ;  run  the 
blade  along  the  surface  of  the  exposed  fat  and  cellular  tissue,  and 
then  thrust  the  point  of  the  forefinger  of  the  left  hand  into  the  wound 
a  little  in  front  of  the  anus,  so  as  to  penetrate  between  the  accelerator 
urina;  muscle  and  the  erector,  —  the  knife  being  applied  to  any  part 
which  offers  resistance;  the  finger  can  now  be  placed  u[)on  the  mem- 
branous portion  of  the  urethra,  and  the  groove  in  the  staff  may  be 
distinctly  felt  ;  carry  the  point  of  the  blade,  with  the  flat  surfaces 
1  G.  Tiemann  tit  Co. 


524 


OPERATIVE  SURGERY. 


nearly  horizontal,  along  above  the  finger,  and  perforate  the  urethra 
about  three  lines  in  front  of  the  prostate,  and  carry  it  along  the  groove 
until  it  has  entered  the  bladder,  having  slit  open  the  side  of  the  ure- 
thra and  notched  the  margin  of  the  prostate  in  its  course  ;  slip  the 
forefinger  of  the  left  hand  slowly  into  the  bladder  along  the  staff,  m 
such  a  manner  as  to  cause  dilatation  of  the  surrounding  textures,  and 
move  its  point  about  in  search  of  the  stone,  which,  being  found, 
should  be  retained  in  a  position  near  the  neck  of  the  viscus  ;  remove 
the  staff,  and  introduce  the  forceps  along  the  upper  surface  of  the 
fino^er,  slowly  withdrawing  the  latter  as  the  former  makes  progress  ; 
their  entrance  Avill  be  denoted  by  a  gush  of  in-ine,  at  which  instant 
the  blades  should  be  separated,  when  on  gently  approximating  them 
the  stone  will,  in  all  probability,  be  felt  inclosed.  If  it  is  not,  the 
process  may  be  repeated,  if  the  water  still  flows,  but  should  the  blad- 
der now  be  empty,  the  closed  blades  should  be  quietly  moved  about 
the  bladder  until  the  stone  is  touched,  and  at  this  time,  in  opening 
and  closing  them,  great  care  should  be  taken  to  avoid  any  injury  to 
the  bladder;  extraction  being  effected,  the  operation  is  completed. 

Unless  the  calculus  be  large  and  palpable,  and  well  ascertained  before,  never 
cut  into  the  bladder  without  feeling  the  concretion  when  the  patient  is  on  the 
operating  table;  in  general,  the  staff  suffices  for  all  the  sounding  which  may 
be  required  at  this  particular  tinie.i 

Before  commencing  the  incisions,  determine  that  the  point  of  the  staff  has 
not  slipped  out  of  the  bladder,  and  place  it  in  the  attitude  in  which  it  is  to  be 
held  afterwards,  and  then  give  it  in  ciiarge  to  the  assistant;  the  length  of  the 
external  incision  in  the  adult  should  be  about  three  inches;  but  if  the  patient 
is  fat,  the  perineum  deep,  and  the  stone  large,  it  should  be  made  longer,  at 
both  ends,  but  more  especially  in  front. i 

A  free  division  of  the  skin  is  a  most  important  fea- 
ture in  the  operation :  but  beyond  this  the  appl 
of   the  knife  should  be  extremely  limited  ; 
of  the  finger  may,  in  general,  be  ihrust  will 
force    into    the   space   between    tiie  accelerat< 
and  erector  penis,  provided  the  superficial 
been  cut  (Fig.  52G).i 

In  a  large  majority  of  cases 
the  opening  in  the  deep  part 
of  the  perineum  and  neck  of 
the  bladder  need  not  at  first 
be  larger  than  what  the  fore- 
finger will  stop,  and  as  tiie 
latter  follows  the  course  of 
the  knife  as  soon  as  it  is  with- 
drawn,  there  M-ill    be  as  yet  ^'°-  ^-'^• 

only  a  slight  escape  of  urine;  but  when  the  forceps  are  used  the  fluid  will  gush 
out  at  once,  at  which  time,  as  already  stated,  the  stone  may  probably  be  seized, 
and  thus  further  dilatation  or  the  reapplication  of  the  knife  may  be  decided  ac- 
1  Sir  W.  Fergusson. 


THE   URINARY  BLADDER. 


525 


cording  to  circtiin<!tances;  it  is  rarely  necessary  to  apply  the  knife  again,  for 
dilatation  or  laceration  is  safer  than  free  incision  into  the  tunics  of  the  bladder 
bej'ond  the  prostate.  1 

The  principal  hazards  i  during  the  operation  are,  wound  of  the  rectum  or  of 
some  large  blood-vessel;  the  former  will  hf  best  avoided  by  keeping  the  knife, 
when  in  the  deep  part  of  the  wound,  chiefly  above  the  finger,  which  mav  also 
be  used  to  depress  the  gut.  Under  the  age  of  puberty  there  is  seldom  anv  an- 
noyance from  hieniorrhage,  but  in  the  adult  there  may  be  both  trouble  and 
danger.  The  superficial  perineal  artery,  or  its  transverse  branch,  is  occasion- 
ally of  such  size,  that,  when  divided,  a  ligature  may  be  necessary;  it  is  usually 
so  near  the  margin  of  the  wound  that  it  can  be  secured  with  great  facility. 
The  artery  of  the  bulb  will  seldom  be  cut,  as  the  point  of  the  knife  should 
never  be  carried  so  high  as  this  part.  Perhaps  the  most  troublesome  ha-mor- 
rhage  may  be  from  the  veins  around  the  neck  of  the  bladder,  which,  in  those 
advanced  in  years,  are  often  of  considerable  size.  If  necessary,  the  opening  in 
the  skin  might  be  enlarged,  to  permit  the  application  of  a  ligature  to  a  deep- 
seated  artery,  and  it  might  even  be  possible  to  carry  a  curved  needle  round  the 
pudic,  were  this  deemed  advisable;  but  in  the  generality  of  instances  the 
bleeding  ceases  as  soon  as  the  patient's  thighs  are  placed  together, — for  theu 
the  cut  surfaces  come  mure  clo-ely  into  apposition. 

Numerous  instrunaetits  have  been  invented  with  a  view  to  give 
greater  precision  to  the  mani[)uhvtions  of  the  opera- 
tor.    The  most  perfect    instrument  '^   is  the  follow- 
ing: — 

It  consists  of  a  catheter  and  lithotome  (Fig.  527).  The /- 
catheter  is  bent  nearly  at  right  a 
rounded  corner,  having  a  strong  h 
shank  of  which  is  fixed  a  hinge  for  th 
of  the  incisor,  which,  when  closed,  s 
slot  at  the  angle,  which  runs  to  the 
and  twists  towards  the  left  side;  in  t 
there  is  a  cup  attached  to  a  band  of 
steel,  which  runs  through  the  upper 
the  catheter,  the  base  of  the  hinge, 
and  the  handle,  to  end  in  a  knob, 
not  shown  in  the  cut.  The  incisor 
being  opened,  as  in  the  cut,  intro- 
duce the  catheter,  the  angle  of 
which  makes  a  prominence  in  the 
perineum,  behind  the  bulb  of  the 
corpus  spongiosum  ;  now  press  the 
incisor  home,  then  withdraw  it, 
and  into  the  opening  thus  made 
introduce  the  point  of  the  litho- 
tome into  the  cup,  when  its  for- 
ward motion  will,  if  it  has  struck 
the  cup,  draw  the  knob  to  the  end 
of  the  handle,  which  will  indicate  that  it  has  engageil  in  the  slot,  and  will 
follow  it  into  the  bladder,  inclining  to  the  left  side  as  it  passes  deep  into  the 
tissues.  ^ 


1  Sir  W.  Fergusson. 


2  X.  K.  Smith. 


526 


OPERATIVE  SURGERY. 


The  treatment  after  lithotomy,  as  regards  diet,  the  state  of  the 
bowels,   and   the  various  evil  consequences  of   the   proceedino-,   not 
particularly  referred  to  above,  —  such  as  infiltra- 
tion, wound    of  the  rectum,  inflammation  of  the 
neck    of    the    bladder   or   of   the 
peritoneum,  —  should  be  conduct- 
ed on  the  ordinary  principles  of 
sui-gery. 

8.  Supra-pubic  lithotomy  is 
performed  only 
when  the  stone 
is  very  large, 
the  patient  not 
overfat,  and  the 
bladder  capable 
of  distention. 
Place  the  pa- 
tient on  a  firm 
table  with  the 
pelvis     slightly 


Fig.  528. 


raised ;  fill  the  bladder  slowly  with  water  until  it  rises  well  above  the 
pubes;  make  an   incision   in  the  median  line, 
commencing  at  the  symphysis,  three  or  four 
inches,  down   to  the  linea  alba;  open  this  for 
about  two  inches  upwards.     Now  pass  the  ca- 
nula   with    the    concealed    trocar 
sonde-a-d;ii'd    into    the    bladder, 
and  protrude  the  trocar  (Fig.  528) ; 
the    bladder    is 
now  to  be  open- 
'^^«--=:s:r^--^a^^^    ed,    the     trocar 
being  the  guide; 
the    hooked- 
gorget  and  spat- 
ula are  now  used 
to    o  {)  e  n    the 
wound  Avhile  the  forceps  are   in- 
troduced (Fig.  529),  and  the  stone 
seized  and  removed.      The  wound 
IiG.  529.  in  the  abdomen  should  be  closed 

with  sutures  and  no  catheter  or  other  instrument  is  required. 

9.  Vesical  calculus  in  women  may  be  removed  by  the  following 
methods:  (1.)  Extraction  through  the  dilated  urethra  may  be  ef- 
fected if  the  stone  is  not  of  large  size  thus  :   give  an  anaesthetic ; 


THE    URETHRA.  527 

place  the  patient  in  the  lidiotomy  position,  and  with  a  dihitor,  con- 
sisting of  two  bhiik's,  or  dre^sing  forceps,  introduced  closed,  distend 
the  canal  forcibly,  until  it  is  of  the  re(inisite  calibre;  seize  the  stone 
with  strong  forceps,  and  slowly  withdraw  it;  in  children,  a  stone  of 
one  iuvh,  and,  in  adults,  a  stone  of  two  inches  in  diameter  may  ije  re- 
moved l)y  rapid  dilatation. ^  (2.)  If  the  stone  is  larger,  crush  it  with 
the  lithotrite,  and  rennjve  the  fragments  with  forceps  and  injections 
of  warm  water.  (3.)  If  the  former  methods  are  not  applicable,  owinor 
to  the  size  of  the  stone,  or  the  intolerance  of  the  bladder,  incision  is 
required,  as  follows:  (1.)  The  canal  may  be  enlarged  by  incision 
made  either  ujjwards^  or  downwards  or  laterally. ^  (2.)  The  blad- 
der may  be  opened  through  the  vagina''  by  cutting  from  l)cfoie  back- 
wards on  a  grooved  director  introduced  through  the  urethra,  and 
made  to  dejn'css  the  vesico-vaginal  septum;  the  wound  must  be  im- 
mediately closed  on  the  extraction  of  the  stone,  as  in  vesico-vaginal 
fistula.  (3.)  The  suprapuljic  method  may  be  praciiced,  when  the 
stone  is  very  large,  in  the  same  manner  as  in  the  male. 


CHAPTER   XLIX. 

THE   URETHRA. 

The  nrethra^  is  a  tube  of  continuous  mucous  membrane,  about 
eight  and  a  half  inches  in  length,  supported  by  an  outer  layer  of 
submucous  tissue  connecting  it  wiih  the  several  parts  through  which 
it  passes,  and  containing  two  layers  of  plain  muscular  fibres,  the 
innermost  being  disposed  longitudinally,  and  the  outer  circularly. 

It  is  divided  into  three  parts:  (1)  the  prostatic,  which  passes  throufch  the  up- 
per part  of  the  prostate  gland,  and  is  the  widest  part  of  the  canal,  being  larger 
in  the  middle  than  at  either  end,  and  twelve  to  fifteen  lines  in  length;  though 
enclosed  in  firm  glandular  substance,  it  is  more  dilatable  than  any  oilu-r  part  of 
the  urethra;  (2)  the  membranous  portion  which  extends  from  the  apex  of  the 
prostate  to  the  bulb,  being  three  quarters  of  an  inch  along  its  anterior,  and  half 
an  inch  on  its  posterior  surface,  owing  to  the  projection  upwards  of  the  bulb ;  it  is 
the  narrowest  division  of  the  urethra;  (3)  the  spongy  portion,  which  includes 
the  remainder  of  the  canal,  is  about  six  inches  in  length,  the  bulbous  portion 
being  tiie  largest;  the  succeeding  portion  of  tiu;  canal  is  of  uniform  size  to  the 
glans,  where  it  again  expands,  forming  the  fossa  navicuiaris,  which  is  from  four 
to  six  lines  in  length,  and  terminates  in  the  vertical  tissure,  meatus  urinarius, 
two  to  three  lines  in  extent. 

1  T.  Bryant.  2  B.  C  Brodie.  8  R.  Listen.  *  J.  M.  Sims. 

6  Quain's  Anatomy. 


528 


OPERA  TI VE  S UR  GER  Y. 


I.     EXPLORATION. 
1.  The  urethra-meter  1  (Fig-  530)  is  designed  to  gain  a  definite 


knowledge   of   the   calibre  of   the  urethral  canal 
without  contraction  of  the  meatus. 


in  cases   with  or 


Fig.  530.2 


It  consists  of  a  small,  straight  canula,  size  Xo.  8  F  ,  terminat- 
ing in  a  series  of  short  metallic  arms,  B,  hinged  npon  the  canula 
and  upon  each  other;  at  the  distal  extremity,  where  they  unite,  a 
tine  rod  rinining  tlirougli  the  canula  is  inserted ;  this 
rod  is  worked  by  a  stationary  screw  at  the  handle 
of  the  instrument,  and  wlien  retracted,  expands 
the  arms  into  a  bulb-like  shape,  A,  ten  millime- 
ters in  circumference  when  closed,  and  capable  of 
expansion  up  to  forty  millimeters;  a  thin  rubber 
stall,  C,  drawn  over  the  end  of  the  closed  instru- 
ment, protects  the  urethra  from  injury,  and  pre- 
vents the  access  of  the  urethral  secretions  to  the 
interior  of  the  instrument.  When  introduced  into 
the  urethra  and  expanded  up  to  a  point  which  is 
recognized  by  the  patient  as  tilling  it  completeh', 
and  yet  easily  moving  back  and  forth,  the  index 
at  the  handle  then  shows  the  normal  circumfer- 
ence of  the  urethra  under  examination;  in  with- 
drawing the  instnnnent,  contractions  at  any  point 
may  be  exactly  measured,  and  anj^  want  of  corre- 
spondence between  the  calibre  of  the  canal  and  the 
external  orilice  be  readily  appreciated.  Among 
the  advantages  claimed  for  this  instrument  are: 
(1)  its  capacity  to  measure  the  size  of  the  urethra, 
and  to  ascertain  the  locality  and  capacity  of  any 
strictures,  without  reference  to  the  size  of  the 
meatus;  (2)  it  enaljles  the  surgeon  to  complete  the 
examination  of  several  strictures  by  a  single  intro- 
duction of  the  instrument,  and  by  reduction  of  its 
size  to  avoid  the  irritation  which  usually  attends 
the  withdrawal  of  the  ordinary  bougie-ii-boule  or 
bulbous  sound. 

2.  The  endoscope  is  an  instrument  for 
the  direct  exploration  of  internal  parts  by 
the  sight,  as  the  interior  of  the  bladder, 
urethra,  rectum,  uterus,  nasal  fossae,  phar- 
ynx, larynx,  and  even,  in  time,  perhai)s 
the  oesophagus  and  stomach;  it  is,  however, 
chiefly  of  use  in  diseases  of  the  urethra. 

It  consists  of  a  tube  or  speculum  of  hard  rub- 
l)er  1  (Fig.  531),  which  is  introduced  into  the  cav- 
ity to  be  examined;  and  at  one  extremity  of  this 
a  mirror  o?  polished  silver,  perforated  in  the  cen- 
tre, is  placed  at  an  angle  of  45°,   to  reflect  the 


Fig.  531.2 


I  F.  N.  Otis. 


2  G.  Tiemann  &  Co. 


THE   URETHUA. 


529 


Fig.  532.1 


light,  wliich  is  placed  laterally,  into  tlie  tube,  so  as  to  illuminate  it  to  the  end; 
as  the  calibre  i>f  the  tube  fs  very  small,  a  most  brilliant  light  is  required,  and, 
in  order  to  ol)tain  the  best  effects,  it  should  be  made  to  converge  slightly  upon 
the  mirror,  l)y  interposing  between  the  light  and  mirror  a  plano-convex  lens 
of  suitable  focal  length.  The  light 
being  sulhcient,  the  lens  properly  ad- 
justed, the  mirror  bright  and  correctly 
placed  with  respect  to  the  tube,  the 
eye  of  the  observer,  looking  through 
the  perforation  in  the  mirror,  can  see 
clearly  to  the  bottom  of  the  speculum.  The  meatoscope  (Fig.  532)  is  for  ex- 
amination of  the  parts  within  an  inch  or  more  of  the  meatus. 

3.  The  circumference  of  the  flaccid  penis  generally  bears  a 
certain  relation  to  tlu'  eapacity  of  tin-  urethral  eanal;  by  taking  the 
measurement  of  the  former  the  calibre  of  the  latter  ean  be  very 
closely  appro.ximated  before  instruments  are  introduced.'^ 

The  following  relations  have  been  noted: 2  penis  3  inches,  canal  30,  of  the 
French  scale;  penis  3i,  canal  32;  penis  3j,  canal  34;  penis,  3?,  canal  36;  penis 
4,  canal  38  ;  penis  4'i  to  41,  canal  40  or  more.  In  every  case  the' urethral  calibre 
is  over  rather  than  under  these  tigures. 

4.  The  catheter,  sound,  and  bulbous  bougie  are  necessary  to 
determine  the  eomlition  of  the  urethra.     One  of  the  most  convenient 

forms  of  catheter  is  the 
velvet-eyed  (Fig.  533), 
which  is  yielding,  and 
creates  no  irritation.  The 
sound  detects  the  presence 
of  solid  bodies,  as  calculi; 
Fig.  .j:;;j.i  the  bulbous  bougie  meas- 

ures the  calibre  and  ex- 
tent of  strictures.  An  olive  point  may  be  fixed  on  the  extremity  of 
a  stilet,  in  a  spiral  tube  or  catheter;  the  catheter  is  introduced  with 
the  bulbous  extremity  withdrawn,  but  when  it  is  arrested  the  bulb  is 
protruded  through  strictured  points. 


II.    DEFECTS. 

1.  Imperforate  urethra  ^  may  consist  of  a  closed  meatus,  which 
must  be  opened  by  puncture  or  incision ;  or  of  a  diaphragm  lower 
down,  which  must  be  perforated  by  a  trocar.  If  the  tube  is  deficient 
throughout,  the  bladder  must  be  opened  bj-  perineal  section,  and  an 
effort  must  be  made  to  construct  a  permanent  passage. 

2.  Hypospadias  *  is  the  result  of  deficiency  of  the  lower  wall  of 
the  urethra,  anil  may  occur  at  any  part  of  the  penis;  in  the  scrotal 
form  the  orifice  is  often  abnormally  large,  and   the  parts  resemble 

1  G.  Tiemann  &  Co.       2  p.  N.  Otis.       3  Sir  H.  Thompson.       ■•  T.  Holmes. 
34 


530 


OPERATIVE  SURGERY. 


those  of  the  female  (Fi'^.  534);  the  most  frequent  location  of  the 

orifice  is  just  behind  the 
glans,  but  the  most  serious 
defects  are  posterior  to  this 
point.  In  some  cases  there 
is  a  shortening  or  retraction 
of  tlie  corpus  spongiosum 
and  fibrous  enveloj^cs  of  the 
corpora  cavernosa,  causing 
incurvation  of  the  penis,  es- 
pecially during  erection. 
Treatment  of  hypospadias  is 
advisable  only  when  it  ap- 
pears to  be  inconsistent  with 
the  power  of  impregnation,  or 
when  the  opening  is  so  small 
as  to  afford  a  real  obstacle  to 
the  passage  of  the  secretions. 


Fig.  534. 


When  the  defect  is  in  the  balanic  portion,  the  following  operation  ^ 
will  prove  most  satisfactory  (Fig.  535): 
Make  longitudinal  incisions  2,  3,  suffi- 
ficiently  far  apart  to  leave  ample  mate- 
rial for  the  new  urethra,  and  4,  5,  one 
quarter  of  an  inch  outside;  dissect  the 
integuments  from  the  spaces  bounded  by 
these  incisions;  preserve  intact  the  mu- 
cous membrane  and  skin  in  all  the  central 
space  included  between  the  incisions  2,  3, 
and  1,  10;  slide  the  loose  skin  at  the  root 
of  the  penis  and  of  the  scrotum  gradually 
forward,  making  it  double  upon  itself  un- 
til 3,  3,  is  brought  to  2,  2,  and  the  denuded 
surfaces  are  brought  into  accurate  appo- 
sition, making  the  angle  of  the  fold  at 
7,  7;  take  the  first  siitare  at  6,  6,  passing 
the  upper  from  within  outwards  and  the  \  A 
lower  from  without  inwards;  before  tying 
the  suture  of  one  side,  pass  that  of  the  Fig.  535. 

opposite  side,  tie  and  cut  the  ends  short,  leaving  the  knot  inside  of 
the  newly  formed  urethra ;  apply  sutures  along  the  external  side  at 
3,  5,  9,  and  2,  4,  8.  The  meatus  becomes  transverse,  its  inferior  lip 
being  the  fold  of  skin  from  10,  formed  by  the  apposition  of  the  points 
3,  3  to  2,  2,  and  its  superior  lip  the  edges  of  mucous  membrane  2,  2. 

1  J.  W.  S.  GoULEY. 


TEE   URETHRA. 


531 


When  tlie  opening  is  belli nd  tlic  gl:ins,  and  the  organ  is  otlierwise 
well  foriiieil,  no  operation  is  reijuired,  or  at  least  only  a  freshening 
of  the  edges  and  their  union  by  suture;  if  the  oj)ening  is  in  the 
penile  portion,  and  the  organ  is  incurved,  the  latter  must  first  be 
relieved  by  subcutaneous  section  of  the  tense  fihrous  structures, 
while  the  organ  is  forcibly  extended;  slight  transverse  incisions  of 
the  skin  may  be  required,  and  when  the  penis  is  extended  these  in- 
cisions will  become  longitudinal,  and  may  be  united  by  suture  in  this 
form.' 

When  the  opening  is  in  the  penile  portion,  several  operations  have 
been  successfully  practiced,  and  are  worthy  of  trial. 

(1  )  Make  an  incision  on  tlie  left  side,  from  the  glans  to  the  scrotum  (Fig. 
530),  tliiini<5ii  the  skin,  half  an  inch  from  the  median  line  and  parallel  to  it; 
froni  each  end  of  this  incision  niake  obliqne  incisions 

to   the  median    line,  and 

dissect   up  the   flap   thus 

formed  ;  make   a   second 

longitudinal    incision    to 

the   right  of  the   median 

line,  but  near   it,  of  the 

same  length,  and  lateral 

incisions  from  each  ex- 
tremity  an    inch    and   a 

half,  and   raise  the  flap; 

introduce  the  sound,  and 

turn  the  first  flap  back- 
wards over  it,  the  epider- 
mic surface   towards   the 

uretlira,  and  insert  sutures 

in  the  margin  ;  put  each 

of   the  ends   through  the 

ej-e   of    a   needle,  which 

must     be     passed     from 

within  outwards  through 

the  base  of  the  other  flap 
(Fig.  537).  and  fastened  by  shot  compressed  upon  it ;  the  right  flap  is  placed 
upon  the  raw  surface  of  the  first,  and  fastened  to  the  margin  of  the  first  incis- 
ion; the  catheter  is  to  be  removed,  but  should  be  introduced  to  remove  the 
water.2 

(2.)  The  meatus  is  first  restored  by  paring  the  two  lips  of  the  notch  which  rep- 
resent it,  and  the  pared  edges  are  united  over  the  end  of  a  probe  introduced;  then 
two  longitudinal  incisions  are  made  from  tlie  glans  nearly  to  the  false  opening 
on  eitlicr  side  of  the  median  line,  and  at  a  distance  from  it  equal  to  half  the 
circumference  of  the  new  uretlira;  at  the  extremities,  transverse  incisions  are 
made  nearly  to  the  median  line;  these  flaps  are  dissected  from  without  inwards, 
and  raised  towards  the  meriian  line  so  as  to  completely  cover  a  sound  of  con- 
venient size  previously  introduced  through  the  newly-formed  meatus;  next, 
the  skin  at  the  sides  is  dissected  up  and  drawn  towards  the  middle  line  to  cover 
1  Bouisson.  2  j.  Anger. 


Fig.  h-K. 


532 


OPERATIVE  SURGERY. 


Fig.  539. 


the  denuded  surface;  the  two  layers  of  skin  are  united  in  the  middle  line,  and 
the  upper  margin  of  each  flap  to  the  lower  margin  of  the  glans,  after  paring; 
the  scrotal  fistula  is  pared  and  united  to  the  newly-formed  canal. ^ 
(3.)  Make  an  incision  near  the  edge 

of  the  fistula  and  extending  beyond  it 

three  eighths  to  one  half  an  inch  at 

each  end,  1, 1  (Fig  .538),  and  dissect  up 

a  flap  bounded  by  the  dotted  curved 

line.     Make  a  curved  incision  on  the 

opposite  side,  and  extending  nearly 

to  the  points  of  the  flrst  incision,  and 

broad  enough  to  include  a  flap  of  suf- 
ficient width  to  cover  the  fistula  and 

reach   the   dotted   curved  line  when 

turned  on  itself ;  scrape  the  outer  sur- 
face of  this  flap  to  remove  the  epider- 
mis, and  dissect  it  up  to  the  edge  of 

the  fistula;  pass  each  end  of  a  thread 

through  a  fine  curved  needle  ;    pass 

these  two  needles  about  one  quarter 

to  one  sixth  of  an  incli  apart  through 

the  edge  of  the  curved  flap  from  the 

epidermic    surface,    and    then    from 

within  outwards  on  the  dotted  line 
border  of  the  flap  formed  by  the  straight  incision;  after  passing  a  sufficient 
nmnber  of  these  sutures,  one  to  every  one  half  or  three  fourths  of  an  inch  (Fig. 
539),  draw  the  curved  flap  under  the  straight  one,  into  the  space  formed  by  dis- 
secting up  the  latter,  so  that  its  edge  will  correspond  to  the  dotted  curved  line, 
and  secure  them  over  a  piece  of  cork;  then  pass  sutures 
across  the  uncovered  space;  uniting  the  edge  of  the  straight 
flap  with  the  skin  on  the  edge  of  the  curved  incision  (Fig. 
540),  and  secure  them. 2 

3.  Epispadias,  defect  in  the  upper  wall  of  the 
urethra,  is  frequently  attended  with  other  deficien- 
cies of  the  neiohborino;  parts  ;  it  may  be  a  slight 
fissure,  or  may  extend  from  the  glans  nearly  to 
the  bladder:  operations  for  its  relief  have  gen- 
erally failed.  The  following  method  deserves 
trial :  — 

The  operation 3  requires  several  sittings.     To  make  the 

meatus  and  parts  belonging  to  the  glans,  two  incisions  are 

required,  one  on  each  side  of  the  groove;  the  surface  of  the 

outer  lip  of  each  incision  is  pared,  and  the  fresh  surfaces 

are  united  with  the  twisted  sutures.    To  make  the  urethra, 

an  incision  is  required  along  the  groove  on  the  right  side, 

and  transverse  incisions  at  its  two  extremities.    On  the 

left   side,   a  similar  incision    is   made   but  three  fourths 

of  an  inch  from  the  groove;  this  flap  is  dissected  up  and  turned  over  to  form  a 

roof  for  the  new  m-ethra,  its  cutaneous  surface  being  turned  downwards;  liga- 

1  S.  Duplay.  2  Szymanowski.  '  Thiersch. 


Fig.  540. 


THE    URETURA.  533 

tiircs  arc  passed  near  its  free  border  and  llieii  llirouf;li  tlic  base  of  tlie  other  flap, 
wliic'li  is  drawn  over  tlie  lirst  so  as  to  l)rinf;  their  raw  surfaces  together;  the 
anterior  space  between  the  new  urethra  of  the  glans  and  of  the  body  is  ch)sed  by 
niakinj;  a  trans\nM^e  incision  tlirouj^h  the  prepuce,  passinj,'  tin;  ghms  through 
it,  and  jiaring  tlie  lionlers  and  attaching  them  to  the  edges  of  the  incision  of 
the  prepuce;  tlie  posterior  portion  of  tlie  canal  is  closed  by  thips  from  either 
groin,  in  the  same  manner  as  the  urethra,  one  being  reflected  to  fdrin  the 
urethra,  the  other  to  cover  the  lirst  Hap;  the  edges  of  the  old  flaps  being  refresh- 
ened. 

III.    INJURIES. 

1.  Simple  incised  wounds^  iu-e  dangerous  in  proportion  to  their 
depth,  as  regards  their  direction  and  the  tissues  involved.  Tlie  in- 
dications are,  to  jirevent  extravasation  of  urine  by  enlargement  of  the 
wound  if  necessary,  or  the  iiitrodiictioii  of  a  catheter. 

2.  Contused  and  lacerated  wounds  generally  residt  from  falls 
astride  of  hard  bodies,  and  are  more  frequently  located  in  that  j)or- 
tion  related  to  the  deep  perineal  fascia,  and  it  is  in  this  jiart  that 
there  is  the  greatest  risk  to  life,  owing  to  the  tendency  to  urinary  in- 
filtration, and  the  liability  to  intrapelvic  suppuration  and  jieritonitis.^ 
The  rupture  is  usually  due  to  the  forcible  pressure  of  the  urethra 
against  the  triangular  ligament.^  The  tube  may  be  torn  partially  or 
completely  across.  The  symptoms  may  be  very  slight,  but  generally 
there  are  contusions,  inability  to  pass  water,  and  bleeding  from  the 
urethra.  At  first,  an  effort  should  be  made  to  pass  a  flexible  cath- 
eter, but  the  utmost  gentleness  must  be  used,  in  order  not  to  engage 
the  point  in  the  rent;  if  the  rent  is  longitudinal,  the  catheter  may 
pass  without  much  dilhcidty  ;3  if  it  is  transverse,  and  involves  only 
the  lower  portion,  the  extremity  of  the  catheter  may  be  passed  along 
the  roof;  in  some  cases  the  stilette  may  be  carried  in  the  flexible 
bougie,  and  when  the  obstruction  is  met  with  by  withdrawing  the 
stilette  an  inch  the  end  of  the  catheter  is  suddenly  raised  and  passes 
the  obstruction.  The  catheter  should  rarely  be  retained  owing  to 
the  liability  to  extravasation  by  its  side.^  If  there  is  hemorrhage, 
ice  must  be  applied.  ]f  the  catheter  cannot  be  passed,  or  there  is  a 
distinct  hard  tumor  at  the  seat  of  injury,  perineal  section  must  be 
at  once  performed  to  give  free  escape  to  the  urine;  pass  a  sound 
down  to  the  ru[)tin-e,  and  make  the  incision  down  to  its  extremity. 

Delay  in  the  performance  of  this  operation  causes  imminent  risk,  and  prob- 
ably an  aggravation  of  the  local  mischief. l  These  lesions  always  render  the 
patient  lialile  to  subsequent  strictures,  often  of  an  intractalile  kind,  and  hence 
the  importance  of  restoring  and  maintaining  the  full  capacity  of  the  canal  in 
tile  subse(|uent  treatment. 

3.  Laceration  of  the  mucous  membrane  of  the  heallhv  urethra 
more  often  results  from  forced  catheterism;  the  catheter  is  usually 

1  J.  BirkpU.  2  J.  "W.  S.  Goulky.  »  s   Rogers. 


534 


OPERATIVE  SURGERY. 


arrested  at  the  triangular  ligament,  and  if  force  is  used  the  mucous 
membrane  yields  and  a  false  passage  results.^  In  the  strictured 
urethra,  lacerations  occur  from  attempts  to  force  a  passage;  the 
point  of  the  catheter  passes  on  the  side  where  pressure  is  greatest. 
These  lacerations  may  lead  to  infiltration,  and  then  incisions  are  re- 
quired, especially  when  the  wound  is  in  the  perineal  portion;  ordi- 
narily, the  false  passage  becomes  a  part  of  the  treatment  of  stricture. 

IV.  FOREIGN  BODIES. 
1.  Substances  introduced  into  the  urethra  from  without  in- 
clude every  variety  of  material,  as  pins,  pencils,  stones,  beads;  they 
tend  to  advance  into  the  bladder,  but,  if  arrested,  they  cause  reten- 
tion, and  finally  ulceration.  Immediate  removal  is  necessary.  The 
most  useful  instrument  is  forceps  with  a  long  handle  which  separate 
only  at  the  blades  (Fig.  5-41) ;  for  bodies  in  the  anterior  part  of  the 


Fig.  542.2 


Fig.  541.2 

urethra,   slender  forceps,  with  suitable  blades  are  necessary   (Fig. 
542);^  pressure  must  be  made  behind  the  body,  if  possible,  to  pre- 
vent its  being  forced  backward  by  the  forceps. 
If  the  body  be  long  and  soft,  as  a  catheter  or  piece  of  wood,  it  may  be 

transtixed  with  a  stout  needle 
through  the  floor  of  the  urethra 
and  the  canal  pushed  back  over 
it,  like  a  glove  over  a  finger,  as 
far  as  possible,  when  it  may  be 
transfixed  again,  and  so  urged 
forward  until  it  can  be  seized  at  the  meatus.*  If  the  body  cannot  be  dislodged 
it  must  be  removed  by  a  longitudinal  incision. 

2.  Calculus  may  lodge  in  the  urethra  in  its  passage  from  the 
bladder ;  or  an  angular  fragment  of  a  crushed  stone.  The  points 
where  it  is  most  liable  to  lodge  are,  (1)  the  membranous  portion,  at 
the  triangular  ligament;  (2)  in  the  middle  of  the  penile  portion;  (3) 
at  the  meatus.  If  the  calculus  is  posterior  to  the  triangular  ligament, 
push  it  back  into  the  bladder  with  a  large  catheter;  if  it  is  immov- 
able without  great  force,  which  must  be  avoided,  it  may  be  forced 
back  by  injections  through  the  catheter,  of  warm  water,  olive  oil,  or 
flaxseed  tea.  If  the  body  is  anterior  to  the  ligament,  it  should  be 
withdrawn  through  the  meatus  by  means  of  the  forceps  mentioned; 
if  this  effort  fails,  the  three-blade  searcher,^  or  trilabe  (Fig.  543),^ 


1  J.  W.  S.  Gouley.  2  Q.  Tiemann  &  Co. 

■4  Van  Buren  and  Keves.         ^  j.  Hunter. 


3  Sir  H.  Thompson. 
6  Civiale. 


THE    URETHRA. 


535 


should  be  employed.     Introduce  the  blades  withdrawn  into  the  han- 
dle, until  the  calculus  is  I'eached;  then  carefully  open  the  blades,  and 


Fig.  543  i 

when  expanded  gently  insinuate  them  beyond  the  stone  ;  now  close 
the  blades,  and  withdraw.  Other  methods  are  the  various  forms  of 
scoops  (FiL:;s.  544,  /')45,  54!)). 


The  scoop  may  consist  of  a  female  and  male  blade;  the  former  may  be  movable, 
or  it  may  be  lixed.  The 
first  sliiiiild  be  introduced 
with  tiie  scoop  straight 
and  the  male  blade  with- 
drawn  (Fig.    545);    the 


<^^ 


scoop  must  bo  insinuated  by  the  side  of  the  stone  until  it  passes  behind,  and 
then  brought  to  a  right  angle  (Fig.  54G);  the  male  blade  should  then  be  forced 


Fig.  549.1 


^WH 


down  by  means  of  the  screw  (Fig.  547),  when  the  stone  is  caught,  and  re- 
moved or  crushed.  If  the  scoop  is  fixed  (Fig.  540 ),  it  must  be  hooked  over  the 
calculus.2    Pass  the  scoop  down  to  the  stone,  compressing  the  penis  behind  it, 

1  (Fig.  548);   bend  the  penis  at  a  right 

anule,  and  crowd  the  point  of  the  scoop 

along  the  wall  of  the  urethra,  2,  until  its 

point  passes  around  the  stone,  3;   now 

,         ..^^^  turn    the  screw,  force  the   stylet  down 

upon  the  stone  (Fig.  550).  and  withdraw 

it.     If  the  stone  cannot  be  removed  by  these  means,  longitudinal  incision  must 

be  made  in  the  median  line. 


1  G.  Tiemann  &  Co. 


Kileijuet. 


536  OPERATIVE  SURGERY. 


V.     STRICTURE. 

Stricture  is  an  abnormal  contrac  ion  of  some  portion  of  tlie  ure- 
thral canal,  which  may  be  transient,  from  spasm  or  congestion,  and 
permanent  or  organic,  from  deposit  in  or  around  the  Avails  of  the 
urethra.^ 

In  the  correct  sense,  there  can  be  only  the  permanent  or  organic  stricture; 
spasm  of  the  urethra  is  doubtless  of  very  frequent  occurrence,  but  does  not, 
properly  speaking,  constitute  stricture;  in  permanent  stricture  there  is  often  a 
very  decided  tendency  to  spasm,  and  intiammator}^  swelling,  sufficient  to  cause 
retention  of  urine,  not  unfrequently  occurs  in  an  already  constricted  canal,  but 
these  conditions  do  not  come  within  the  detinition.2 

1.  Spasmodic  stricture  may  be  caused  by  a  local  lesion,  as  par- 
tial organic  stricture,  or  by  excitement  existing  elsewhere,  as  in- 
flamed hiemorrlioids.^  Contraction  of  the  meatus  and  slight  organic 
stricture  of  the  anterior  portions  of  the  urethra  will  cause  spasmodic 
stricture  of  the  deeper  parts  closely  resembling  deep  organic  stric- 
ture.3  The  distinguishing  feature  of  this  form  of  stricture  is  its  tran- 
sient character,  and  the  return  of  the  urethra  to  its  natural  degree 
of  patency.^  The  treatment  consists  in  relieving  the  bladder  by  a 
hot  bath,  rest,  and  opiates,  or  at  once  by  <m  anaesthetic  and  catheter; 
the  removal  of  the  cause  must  follow,  as  the  correcton  of  vicious 
habits,  the  gouty  diathesis,  or  concentrated  urine;*  the  contracted 
meatus  must  be  enlarged,  and  the  slight  stricture  dilated.^ 

2.  Permanent  stricture  results  from  organic  deposit  in  or  around 
the  walls  of  tbe  urethra,  due  to  inflammation  following  injuries,  or 
irritants  of  the  mucous  membrane.  It  may  vary  in  the  degree  of  con- 
striction from  a  slight  diminution  of  the  calibre  of  the  urethra,  stric- 
ture of  large  calibre,^  to  the  almost  complete  closure  of  the  tube.  In 
ordinary  cases,  the  following  forms  are  recognized,  namely,  (1)  the 
linear,  (2)  annular,  (3)  tortuous.  Stricture  may  occur  at  any  point 
in  the  urethra,  but  in  searching  for  it  the  natural  narrowing  of  the 
passage  must  be  remembered. 

The  locality  of  organic  stricture  is  variously  given.  The  examination  of  270 
museum  specimens  proves  that  the  order  of  frequency  of  strictures  is  as  follows: 
(1)  At  the  junction  of  the  spongy  and  membranous  portion,  and  an  inch  before 
and  three  fourths  of  an  inch  behind  that  point,  67  per  cent.;  (2)  tlie  spongy  por- 
tion, to  within  two  inches  and  a  half  of  the  external  meatus,  IG  percent.;  (3) 
within  two  inches  and  a  half  of  the  meatus,  17  per  cent.i  Measurements  by 
the  urethra- meter,  in  258  living  subjects,  give  very  different  results,  as  follows: 
in  the  first  quarter  inch,  52;  in  tlie  following  inch,  03;  next  inch,  48;  next  inch, 
48;  next  inch,  19;  next  inch,  14;  next  inch,  8;  next  inch,  6.3 

The   symptoms   of   stricture   depend  upon   its   stage.     A  chronic 
1  Sir  H.  Thompson.  2  J.  w.  S.  Gouley.  3  p.  N.  Otis. 

*  Van  Buren  and  Keves. 


THE   URETHRA. 


537 


urethral  discliarge  is  an  invariable  sign  of  stricture, ^  and  should 
always  lead  to  an  examination  with  suitable  instruments;  -  pain  is 
usually  felt  in  the  urethra  behiml  the  strieture  <it  the  time  of  mic- 
tin'ition  ;  urination  is  increased  in  fre<jneney,  and  the  stream  is  al- 
tered in  form,  lieeoming  more  or  less  flattened,  perhajjs  twisted, 
spirting,  forked,  or  even  divided;  as  contraction  increases  the  strci-.m 
grows  smaller,  the  force  of  the  current  is  lost,  the  act  of  micturition 
is  more  frecjuent  and  prolonged  ;  in  the  worst  cases  there  are  almost 
constant  efforts  to  obtain  relief  by  change  of  posture  and  straining, 
with  tenesmus  of  the  rectum  and  protrusion  of  the  mucous  mem- 
brane;  finally,  retention  becomes  more  and  more  frequent,  with  the 
incontinence  due  to  a  distended  bladder.^  These  symptoms  are  not 
suflicient  alone  to  establish  the  presence  of  stricture,  and  it  is  neces- 
sary to  explore  the  urethra;  with  an  instrument,  its  existence  may 
be  ascertained,  its  location  and  calibre,  and  whether  more  than  one 
is  present.^  It  is,  however,  always  necessary,  in  the  detection  of 
slight  contractions  to  know  the  normal  calibre  of  the  urethra  in  each 
particular  case,  for  every  urethra  has  a  distinct  individuality,  irre- 
spective of  standards,  or  even  of  general  physical  proportions. ^ 

It  is  a  very  common  error  to  suppose  that  when  a  No.  10  or  12  in.strument  is 
passed  a  patient  has  no  stricture,  for  one  adult  may  liave  a  perfectly  healthy 
urethra  so  small  as  to  admit  only  a  No.  8  or  9  sound,  while  aiiollier  man's 
urethra  may  admit  No.  IG,  17,  or  18  and  I)e  constricted;  it  is  necessary,  there- 
fore, to  be  governed  by  the  normal  calibre  in  each  individual  case.* 

Complete  freedom  from  stricture  can  only  be  demonstrated  by  the 
easy  passage  of  a  bulbous  sound  of  a 
size  fully  equal  to  the  normal  calibre 
of  the  presenting  urethra;  this  calibre 
should  first  be  accurately  determined 
by  the  urethra-meter,  or  by  the  less 
accurate  method  of  measuring  the  cir- 
cumference of  the  flaccid  jjcnis.^ 

The  simplest,  and  best  of  all  the  explorers 
now  in  use,  is  the  bulbous  bougie  ( Fig.  551 ), 
of  various  sizes  5  which,  owing  to  the  flex- 
ibility, accommodates   itself  to  the  curves 
of  the  urethra,  and  yields  to  the  slightest 
obstruction,  (lualities  which  render  it  inli- 
!•       nitoly  more  delicate  than   metallic  instru- 
^^      meiits.*      An  instrument   of    wider  range 
and  greater  endurance  is  the  bull)Ous  souiul 
(Fig.  552),  which  consists  of  a  metallic  bulb  of  olive 
shape,  attached  to  a  slender  copper  shaft;  for  convenience  the  bulbs  may  screw 
upon  a  connnon  handle.  ^ 

1  F.  N.  Otis.  2  H.  Dick.  3  Sir  II.  Thompson.  ■<  J.  W.  S.  Uouley. 

6  Lerov  d'Etiolles.  6  Codmau  &  .ShurtlclT. 


Fio.  552. 


538 


OPERATIVE  SURGERY. 


Before  commencing  the  direct  exploration  of  the  urethra,  it  is  de- 
sirable to  see  the  patient  urinate,  in  order  to  ascertain  the  size  and 
form  of  the  stream;  the  glans  should  then  be  examined,  and  the  po- 
sition and  size  of  the  meatus  ascertained. ^ 

Contractions  of  the  meatus  are  a  fruitful  source  of  failure  to  appreciate  ab- 
normal narrowings  of  the  urethra;  the  complete  suppleness  and  resiliency  of  the 
tissues  of  the  normal  meatus  is  a  good  test  of  its  freedom  from  organic  stricture, 
but  congenital  contractions  to  a  greater  or  less  extent  are  not  infrequent;  hence 
both  the  natural  suppleness  and  resilienc}'  may  be  present,  and  the  deformity 
may  escape  notice,  unless  carefully  sought. -^ 

As  a  rule,  whenever  a  bulbous  sound  can,  by  gentle  pressure  three 
or  four  mintues,  be  made  to  slip  into  the  fossae  navicularis,  and  in 
the  withdrawal  is  abruptly  arrested,  the  indication  for  the  free  divis- 
ion of  the  meatus  is  positive,  for  without  it  no  efficient  exploration 
of  the  deeper  parts  can  be  effected.^  The  meatus  must  be  enlarged 
by  an  incision  on  the  inferior  wall  of  the  canal  with  a  bulb-pointed 
bistoury,  and  to  an  extent  which  will  allow  the  passage  of  the  bul- 
bous sound  with  the  utmost  freedom.^  Now,  introduce  a  well-oiled 
instrument,  as  large  as  the  orifice  will  admit,  and 
pass  it  slowly  along  the  canal  till  it  meets  an  ob- 
stacle which  presents  a  positive  hindrance  to  its 
progress  (Fig.  553);  mark  the  stem  of  the  bougie 
with  the  nail,  and  withdraw  and  measure  to  as- 
certain tlie  location  of  the  stricture,  select  a 
smaller  instrument  and  pass  it  beyond  the  obsta- 
cle (Fig.  554) ;  on  withdrawing  the  bulb  the  base 
will  present  at  the  vesical  extremity  of  the  stric- 
ture; if  the  measurement  is  repeated  and  the  p  gg^ 
difference  is  added  to  the  length  of  the  smaller 
bulb,  the  length  of  the  stricture  will  remain  ;  these  bougies  aid  in 
ascertaining  the  form,  diameter,  and  number  of  strictures,  the  tender 
spots  in  the  urethra,  and  the  presence  of  pus.^ 

Stricture  should  be  cured  at  every  stage,  for  if  the  balance  between 
the  natural  expulsive  force  of  the  bladder  and  the  friction  of  the 
stream  alontr  the  urethra  are  disturbed,  the  bladder  is  irritated,  the 
kidneys  are  affected,  and  the  beginning  of  the  long  chain  of  events, 
which  terminate  not  infrequently  in  death,  is  made.^  Treatment  is 
directed  (1)  to  restore  the  natural  calibre  of  the  canal,  and  (2)  to 
maintain  its  adequate  patency;  as  strictures  vary  in  amount  of  con- 
traction, in  dilatibility,  in  disposition  to  return,  in  local  sensibility, 
and  in  liability  to  manifest  sympathy  with  other  parts  of  the  body, 
various  modes  of  treatment  are  necessary  and  appropriate  to  differ- 
ent cases.*  These  different  methods  will  be  appreciated  in  connec- 
tion with  special  degrees  and  conditions  of  stricture. 

1  J.  W.  S.  Gouley.  2  p.  n.  Otis.  3  b.  Hill.  *  Sir  II.  Thompson. 


Fig.  553. 


THE   URETHRA.  539 

Strichircs  at  or  noar  the  meatus^  t^hoiild  lie  treated  In  division  on 
tlie  inferior  wall  of  the  eanal,  witii  a  strai>j;lit  bullj-poinied  bistoury; 
the  utmost  freedom  to  the  passai^e  of  tlie  ljull)ous  soiiml  must  Ije  ob- 
tained, and  not  a  single  trace  of  eontraetion  left  uncut.  Means  must 
be  used  to  prevent  inflammation,  as  rest,  and  cold  water  applications. 
Strictiu-es  of  larLje  caiiljre,  or  incipient  strictures,  in  tlie  pendulous 
urethra,  must  be  treated  by  a  process  of  divulsion  and  nn-tlirotomy 
■which  results  in  a  complete  rupture  or  division  of  every  fibre  of  the 
contraction;  no  one  instrument  can  ever  be  depended  on  to  succeed 
completely  in  all  cases;  in  ordinary  stricture  the  dilating  urethrotome 
is  more  easy  of  management. 

It  consists  of  a  dilating  apparatus  which,  when  closed,  is  equal  to  about  twenty 
of  tlie  French  scale;  upon  its  superior  aspect  a  blade,  tjuanled  at  the  top,  is  slid 
down  throuj^h  a  groove  to  the  end  of  the  shaft;  the  screw  at  the  liandle  is  then 
slowly  turned  until  the  handle  on  the  dial  indicates  that  the  instrument  is  dilated 
up  to  two  or  three  millimeters  beyond  the  jtreviously  ascertained  normal  calibre 
of  the  canal;  the  blade  is  then  slowly  withdrawn,  cutting  through  all  tlie  stric- 
ture on  the  superior  wall  of  the  urethra;  the  instrument  is  now  withdrawn  and 
a  full  sized  bulb  passed;  if  any  fibres  of  the  stricture  remain,  the  operation  must 
be  repeated  at  the  contracted  point  until  perfect  freedom  is  secured. 

Cold  should  be  applied  as  before,  and  sounds  may  be  passed  to 
separate  the  cut  surfaces,  not  to  cause  dilatation,  but  their  use  must 
be  discontinued  as  soon  as  a  full-sized  bulb  can  be  passed  through 
and  beyond  the  previous  site  of  the  stricture  and  withdrawn  without 
a  trace  of  blood. ^ 

Kecontraction  of  stricture,  after  operation,  is  due  to  incomplete  division,  and 
this  will,  as  a  rule,  be  detected  within  one  week,  or,  at  most,  two  weeks,  by 
which  time  the  stricture  tissue  distended,  and  not  divided,  will  sufficiently  re- 
contract  to  become  readily  recognizable  by  the  full-sized  bulb.l 

Strictures  of  a  calibfe  of  less  than  16  or  18  of  the  French  scale, 
or  7  or  9  of  the  English,  require  enlargement  by  gradual  dilatation 
with  soft  bougies,  when  they  are  well  borne,  but  if  not,  by  divulsion; 
after  having  been  broujiht  up  to  a  capacity  permitting  the  passage  of 
the  dilating  urethrotome,  complete  division  of  the  stricture  should 
be  effected  by  means  of  that  instrument.' 

Dilatation  is  the  mildest  and  most  desirable  treatment,  being  generally  appli- 
cable, and  best  adapted  to  a  veiy  large  proportion  of  cases;  in  ordinary  cases  a 
flexible  bouoie,  as  large  as  the  stricture  will  easily  admit,  should  be  passed 
fairly  through  it,  and  then  at  once  withdrawn  with  gentleness;  in  two  or  three 
days  it  is  repeated,  and  if  the  bougie  passes  with  ease,  one  of  larger  size  must 
be  introduced;  gradual  advance  must  then  be  made  until  12  or  13  can  be 
passed.-  But  dilatation,  temporary  or  persistent,  is  never  more  than  a  palliative 
measure,  unless  carried  to  a  point  sufHcient  to  completely  rupture  tlie  stricture. i 

To  treat  a  stricture  by  divulsion  is  to  make  a  longitudinal  rent  of  the  con- 
stricted portion  of  the  urethra ;  this  may  be  accomplished  by  the  successive  ia- 

1  F.  N.  Otis.  -  Sir  H.  Thompson. 


540 


OPERATIVE  SURGERY 


troductioii  of  conical  sounds,  of  different  sizes,  which  act  on  the  principle  of  a 
wedge,  or  by  any  of  the  various  divulsors.i  There  are  three  instruments  well 
suited  for  the  treatment  of  stricture  by  this  method, 2  namel}',  (1)  The  tirst  3  con- 
sists of  two  parallel  blades,  slightly  curved  towards  the  beak  at  which  they  are 
joined;  the  blades  may  be  separated  laterally  to  the  desired  extent  by  turning 
the  handle;  the  shaft  is  marked  by  lines  one  inch  apart  to  indicate  the  depth  to 
which  it  penetrates.  This  instrument,  as  modified,  bv  reducing  the  size  of  the 
shaft  and  tunneling  the  beak  (Fig-  555),  so  that  it  may  be  introduced  through 
small  strictures,  is  to  be  preferred. 1  In  using  this  instrument  the 
depth  of  the  stricture  must  first  be  accurately  determined  by  the  [ 

bulbous  bougie  ;  the  metallic  slide  is  then  pushed  down  upon  the 


Fig.  555.* 

closed  instrument  until  its  point  of  greatest dilatabilitj'  equals  the  distance  from 
the  meatus  to  the  centre  of  the  stricture;  no  anjESthetic  is  required;  pass  the 
instrument  into  the  urellira  until  the  meatus  is  touched  by  the  slide,  and  the 
greatest  dilatibility  corresponds  to  the  centre  of  the  stricture;  now  turn  the 
handle  rapidly  until  the  blades  have  been  separated  to  an  extent  several  sizes 
larger  than  the  patient's  meatus  will  admit;  the  failure  of  the  operation  is  due  to 
the  employment  of  too  little  force  ;  it  is  better  to  tear  too  much  than  too  little,  as 
it  is  only  the  stricture  which  yields;  the  flow  of  blood  is  evidence  of  ruptuie.2 
(2.)  The  second  form  of  divulsor^  consists  of  two  grooved  blades  fixed  in.  a  di- 
vided handle  (Fig.  556),  containing  a  wire  welded  to  their  points;  on  this  wire  a 


Fig.  556.4 

tube  corresponding  to  the  natural  calibre  of  the  urethra  is  quickly  passed  and 
ruptures  or  splits  the  obstruction;  the  instrument  should  first  be  passed  into  the 
bladder,  when  a  few  drops  of  water  will  escape,  then  place  the  tube  selected  on 
the  wire  and  thrust  it  quickly  onwards  to  the  end,  now  rotate  the  shaft  and 
withdraw  it,  and  substitute  a  catheter  of  equal  size.  (3.)  The  third  form  6  re- 
sembles the  .second  in  having  two  parallel  blades,  but  they  act  by  fitting  into 
grooves  of  snlid  conical  and  cylindrical  shafts;  the  blades  are  first  introduced 
closed,  and  then  the  shaft  selected  is  fitted  into  the  grooves  and  driven  forcibly 
home,  separating  the  blades  laterally. 

The  defect  in  these  instruments  is  their  want  of  adaptability  to  the  dimensions 
of  the  stricture  upon  which  operation  is  required;  the  amount  of  resiliency  of 
the  stricture  in  tl)e  flaccid  urethra  is  undetermined,  and  hence  the  divulsing 
shaft  is  selected  without  exact  data,  and  the  size  of  the  blade  in  the  cutting  in- 

1  J.  W.  S.  Gouley.  2  Van  Buren  and  Keyes.  ^  .Sir  H.  Thompson. 

i  G.  Tiemann  &  Co.  5  B.  Holt.  6  Voillemiers. 


THE   UnKTIIRA. 


541 


fl^ 


strument  being  left  to  conjecture  is  liable  to  be  unsuited  to  the  case.*    There  is, 
therefore,  need  of  an  instrument  which  will  supplement  the  other  divulsor  and 
prove  reliable  in  the  complete  division  of  the  stricture  and  the  enlargement  of 
A  the  calibre  of  the  urethra  to  its  full  normal  capacity.     This  is 

found  in  the  following  dilating  urethrotome  (Fig.  557):  i  A 
pair  of  steel  shafts,  A,  B,  are  connected  by  short  pivotal  bars ; 
the  expansion  and  contraction  are  effected  by  means  of  a  screw 
in  the  handle,  connected  with  the  lower  shaft,  and  moved  by  a 
finger  button,  C;  short  curved  registering  arms,  at  D,  mark 
the  divisions  of  the  American  and  French  scale;  a  scale  of  inches 
Kflll  *"*^  quarter  inches  are  marked  on  the  shaft,  B,  by  which  its 

depth  in  the  urethral  canal  is  rated;  the  upper  bar  of  the  instru- 
ment is  hollowed  out,  and  traversed  by  a  urethrotome;  bv  the 
metallic  handle,  G,  of  the  urethrotome,  it  is  moved  at  will 
through  the  entire  length  of  the  shaft,  A ;  a  small  button,  ff, 
secures  the  canula  at  any  point  ;  running  through  the  canula, 
and  attached  to  the  handle,  /  ,  is  the  staff  of  the  urethrotome, 
which,  when  at  the  extremity  of  the  canula,  is  concealed  in  the 
deep  groove;  on  withdrawing  the  handle,  /,  the  canula  being 
firmly  fixed  at  any  given  point  b}'  the  button-screw,  //,  the 
spring  blade, ./.  rises  out  of  the  groove  by  means  of  a  little  ele- 
vation on  its  flo<  r.  rides  over  it,  displaying  the  full  width  of  its 
blade  for  half  an  inch,  then  drops  into  the  groove  and  is  con- 
cealed. The  instrument  is  used  as  follows:  Introduce  it  with 
the  urethrotome  beyond  the  known  point  of  stricture.  Now  di- 
late the  shafts,  A,  B,  until  the  stricture  is  made  tense  ;  turn 
the  button-screw,  11,  releasing  the  canula.  which  must  be  drawn 
outwards  until  the  knob  of  the  urethrotome,  beyond  J,  is  ar- 
rested; the  canula  is  then  advanced  half  an  inch,  and  fi.xed, 
and  then  by  a  rapid  movement  outward  of  the  handle  of  the 
urethrotome  the  blade  is  brought  up  through  the  stricture  from 
behind  forwards  ;  the  finger-button,  C,  is  again  turned  and  the 
shafts  separated,  to  determine  whether  the  stricture  is  completely 
divided;  if  not,  the  knife  may  be  passed  from  before  backwards. 

There  is  a  class  of  small  strictures  with  tortuous  or 
false  passages  which  require  the  use  of  filiform  bougies, 
as  guides  to  other  sounds;  these  guides 
are  made  of  whalebone,  of  various  sizes 
down  to  that  of  a  horse-hair;  thcv  are 
onlinarily  twelve  inches  lona,  with 
straight,  angular,  and  spiral  points 
(Fig.  55!^).  They  are  used  as  fol- 
lows :  ^  Inject  oil  into  the  urethra; 
then  introduce  the  bougie,  straight 
or  bent,  along  the  floor  of  the  canal  to 
avoid  the  lacuna  magna;  if  it  enter  a  lacuna,  withdraw, 
and  change  the  direction;  in  exploring  for  the  entrance 
of  a  stricture,  a  slight   to-and-fro   motion    should  be 


/ 


Fig.  558.- 


^  F.  N.  Otis. 


8  G.  Tiemann  &  Co. 


8  J.  W.  S.  Goulev. 


542 


OPERATIVE  SURGERY. 


given;  if  the  effort  fail  with  one  form,  another  must  be  substituted, 
and  the  whole  calibre  of  the  urethra  must  be  examined  ;  if  the 
sound  has  passed  the  stricture,  it  will  be  movable  back  and  forth; 
if  it  enter  a  false  passage,  allow  it  to  remain,  and  pass  others  by  its 
side  until  one  passes  on  into  the  bladder.  Having  reached  the  blad- 
der, the  bougie  serves  as  a  conductor  upon  which  the  tunneled  sound 
(Fig.  559),  may  pass,  and  both  dilate  and  straighten  the  stricture.^ 
The  tunneled  sound  i  is  a  grooved,  conical  steel 
sound  witli  a  canal  one  eiglith  of  an  inch  in  length 
at  the  vesical  extremity,  and  witli  a  curve  equal 
to  one  fifth  the  circumference  of  a  circle  three 
and  one  quarter  inches  in  diameter;  the  smallest  is  one  and  a 
half  millimeters  in  diameter  at  the  point;  when  the  guide  has 
entered  the  bladder,  the  free  end  is  slipped  through  the  tun- 
nel of  the  smallest  sound,  which  is  carried  down  to  the  obsta- 
cle, and  held  in  firm  contact  with  it  for  a  few  moments,  when 
the  instrument  will  pass,  but  no  undue  pressure  should  be  used; 
larger  instruments  should  be  passed  at  the  same  sitting,  up  to 
four  or  five  higher  numbers.i  The  stricture  may  now  be  fully 
dilated  by  the  dilating  urethrotome. 2 

In  many  obstinate  cases,  incision  of  the  stricture 
becomes  a  necessary  and  important  part  of  the  treat- 
ment. This  incision  may  be  (1)  internal,  internal 
urethrotomy,  or  (2)  external,  perineal  urethrotomy. 

1.  Internal  urethrotomy  is  performed  with  a  great  varietj' 
of  instruments,  but  they  may  be  usefully  classified  into,  (1) 
those  adapted  to  the  smallest  stricture,  and  (2)  to  strictures  of 
the  calibre  of  Nos.  4,  5,  or  6.     For  the  former,  use  the  tun- 
neled urethrotome  (Fig.  560), i  as  follows:  i    Pass  the  capil- 
lary conductor  into  the  bladder  ;  slip  the  distal  end  through  the 
smallest  tunneled  sound,  and  dilate  the  stricture  a  little  to  fa- 
cilitate the  entrance  of  the  urethrotome  ;   remove  the  sound, 
and  introduce  the  tunneled  urethrotome,  and  divide  the  stric- 
FiG.  559.3     j^ij.g  f,.f„^^  before  baclcwards  by  sliding  the  instrument  gently 
upon  the  conductor  until  all  resistance  to  its  passage  ceases;  withdraw  the  ure- 
throtome, leaving  the  conductor  in  position  ;  now  pass  a  large  tunneled  or  other 


Fig.  560.8 


catheter  to  ascertain  if  the  incision  has  been  sufficiently  free.i  The  stricture 
may  be  divided  from  behind  forward,  but  to  make  this  incision,  the  stricture 
must  admit  the  part  of  the  instrument  concealing  the  blade;  this  requires  the 
dilatation  of  the  stricture  to  No.  3  or  4/*  But  when  dilatation  has  reached  that 
degree,  the  principles  which  govern  in  resorting  to  the  dilating  urethrotome  in 

1  J.  W.  S.  Goulev.  2  F.  N.  Otis.  3  q.  Tiemann  &  Co. 

*  Sir  H.  Thompson. 


THE   URETHRA. 


543 


Fig.  .■.<;!. •' 
1  J.  \V.  S.  Gouley. 


strictures  of  large  calibre  should  be  applied  to 
tliese  strictures  of  small  calibre. i  The  instrument 
for  this  operation  combines  (lila(atioi)  with  incis- 
ion (Fig.  5G1);"'^  its  application  is  apparent. 

2.  External  or  perineal  urethrotomy  is  re- 
quired when  dilatalion  is  unsuccessful,  or  iujprac- 
ticable,  or  there  are  fistulous  passages.  In  some 
cases  it  may  be  possible  to  pass  a  grooved  staff 
through  the  stricture,  which  greatly  simplifies  the  opera- 
tion; in  other  cases  the  stricture  is  so  light  as  to  admit 
only  a  filiform  bougie,  which  is  an  important  guide,  but 
a  certain  number  are  aliogcther  impassable,  and  the  sec- 
tion must  be  made  without  a  guide.  For  several  days 
before  the  operation,  when  there  is  no  urgency,  it  is  well 
to  direct  the  patient  to  assume  the  recumbent  position 
and  take  a  hip  bath  every  night,  also,  ten  drojjs  of  tr. 
ferri  chloridi  three  times  daily,  and  five  grains  of  quinine 
at  bed-time,  with  a  suppository  of  one  grain  of  opium  and 
half  a  grain  of  the  extract  of  belladonna  eveiy  night;  the 
bowels  must  be  moved  by  oil  and  an  enema  before  the 
operation.!  Operate  as  follows ;  After  filling  the  urethra 
with  olive  oil,  introduce  a  capillary  probe-pointea  whale- 
bone bougie  into  the  urethra;  if  its  point  enter  a  false 
|)assage,  pass  others  by  its  side  until  one  enters  the  blad- 
der; upon  this  guide  i)ass  a  tunneled  groove  staff  into 
the  bladder;  by  the  rectuui  explore  the  membranous  and 
prostatic  divisions  of  the  urethra;  now  make  a  free  in- 
cision in  the  median  line  of  the  perineum,  extending 
from  the  base  of  the  scrotum  to  within  half  an  inch  of  the 
anus,  involving  skin  and  superficial  fascia;  continue  the 
dissection  until  the  urethra  is  brought  into  view;  open 
the  canal  upon  the  groove  of  the  .staff,  pass  a  thread  of 
silk  through  each  edge  of  the  incised  urethra  with  which 
the  wound  may  be  kept  open  by  an  assistant;  with  a 
beaked,  narrow,  straight  bistoury,  passed  along  the 
guide,  divide  the  stricture  and  half  an  inch  of  the  uncon- 
tracted  canal  behind  it;  now  pass  the  catheter,  guided  by 
the  whalebone  bougie,  into  the  bladder;  if  it  is  ob- 
structed, extend  the  incision.  The  after  treatment  should 
be  ten  grains  of  quinine  and  one  fourth  of  a  grain  of  mor- 
phia immediately  to  prevent  fever;  three  grains  of  qui- 
nine, daily,  with  iron,  for  two  or  three  weeks,  and  warm 
hip  baths  ;  on  the  second  day  a  full-sized  conical  steel 
sound  is  passed,  and  repeated  every  third  day  until  the 
wound  is  healed. 

If  the  stricture  is  impassable,  pass  a  large  sound  until  it 
rests  ujion  the  face  of  the  strictm-e;  an  assistant  holds  it 
firmly  and  draws  the  scrotum  upwards;  the  dissection  is 
the  same  as  the  preceding,  until  the  soimd  is  exposed; 
insert  threads  into  either  margin  of  the  urethra  with  which 
to  keep  the  wound  open  ;  with  small  grooved  directors, 
search  for  the  contracted  passage,  and,  if  found,  pass  the 

2  F.  N.  Otis.  •  Geo  Tiemann  &  Co. 


544  OPERATIVE  SURGERY. 

director  as  far  as  possible  and  enlarge  it  by  incision;  continue  tliis  method  of 
dissection  until  the  passage  is  complete;  if  the  director  cannot  be  introduced, 
make  the  dissection  accurately  in  the  line  of  the  canal;  as  soon  as  the  conti- 
nuitv  is  restored,  introduce  a  full-sized  sound;  repeat  the  passage  of  the  sound, 
as  before,  but  do  not  allow  it  to  be  retained. 

3.  Tapping  the  urethra  at  the  apex  of  the  prostate  by  perineal  incis- 
ion 1  is  a  rapid  method  of  relieving  the  distended  bladder  in  impassable  stricture, 
as  follows:  Place  the  patient  in  the  lithotomy  position ;  introduce  the  left  fore- 
finger into  the  rectum  and  place  its  tip  on  the  apex  of  the  prostate;  plunge  a 
double-edged  knife  into  the  median  line  of  the  perineum  and  carry  its  point 
forward  towards  the  tip  of  the  finger,  enlarging  the  external  wound  bj'  an  up- 
ward and  downward  movement;  when  the  point  is  felt  near  the  finger's  end, 
it  is  made  to  open  the  urethra  by  a  slight  movement  to  the  right  or  left;  now 
withdraw  the  knife  and  introduce  a  probe  or  director  into  the  urethra  and  thence 
into  the  bladder;  withdraw  the  finger  from  the  rectum,  and,  holding  the  director 
with  the  left  hand,  pass  a  large  catheter  into  the  bladder.  This  new  opening 
may  be  made  permanent;  i  or  the  stricture  may  be  cut  through  in  front,  a 
catheter  passed,  and  a  new  urethra  established.^ 

VI.    THE  FEMALE  URETHRA. 

1.  Catheterism  of  the  female  urethra  is  effected  as  follows :  the 
patient  lying  on  the  back,  completely  covered,  with  the  knees  flexed, 
stand,  if  convenient,  upon  the  right  side;  holding  the  short  catheter, 
well  oiled,  between  the  thumb  and  second  finger  of  the  right  hand, 
the  point  resting  near  the  tip  of  the  index  finger,  pass  the  hand 
under  the  thigh,  carry  the  index  finger  between  the  labia  to  the  en- 
trance of  the  vagina,  where  the  meatus  will  be  detected  as  a  slight 
elevation  with  a  central  depression;  as  the  tip  of  the  finger  rests  on 
the  posterior  edge,  glide  the  catheter  forwards  and  into  the  meatus 
with  the  thumb  and  second  finger. 

Or.  the  gum  elastic  catheter  may  be  used,  which  must  be  introduced  with  the 
left  hand  carried  above  the  thigh,  after  the  right  index  finger  has  detected  the 
meatus.  This  simple  operation  may  prove  very  difficult  and  embarassing,  and 
exposure  of  the  parts  may  be  necessary  for  its  completion. 

2.  Stricture  may  occur  from  injur}',  gonorrhoea,  or  chancre,  and 
is  usually  located  near  the  meatus.  It  must  be  treated  by  dilatation, 
and,  if  necessary,  add  incision. 

3.  Prolapsus  urethrse^  consists  of  prolapse  of  the  urethral  mu- 
cous membrane;  it  is  not  frequent,  but  causes  considerable  irritation 
of  the  urethra  and  bladder,  and  is  often  mistaken  for  irritable  carun- 
cle. It  appears  as  a  red  projection  encircling  the  meatus,  more  or 
less  sensitive,  and  liable  to  bleed;  it  may  exist  for  a  time  without 
symptoms,  but  finally  causes  painful  micturition,  leucorrhoea,  and 
local  irritation.  Seize  the  prolapsed  circle  with  tooth-forceps,  and 
cut  it  off  with  curved  scissors.  Or,  include  the  mass  in  ligatures; 
or,  use  the  galvano-cautery  with  wire. 

1  E.  Cock.  2  C.  J.  Guthrie.  3  T.  G.  Thomas. 


X. 

THE    GENERATIVE    ORGANS 

THE  MALE  ORGANS. 


CHAPTER   L. 

THE  TESTICLES. 

The  testicles  are  two  glandular  bodies  which  secrete  the  spermatic 
Hquid,  and  are  suspended  within  the  scrotum,  one  on  each  side  by 
the  spermatic  cords.  ^ 

I.  THE  SCROTUM. 
The  scrotum  is  the  pendent  pouch  below  the  pubes  containing  the 
testicles;  the  skin  is  thin,  darker  than  elsewhere,  more  or  less 
wrinkled,  and  marked  in  the  median  line  by  a  slight  ridge,  the 
raphe;  the  inner  ])ortion  of  the  skin  is  composed  of  pale  and  un- 
striatod  muscular  fil)res,  the  dartos.^ 

1.  Contusions  of  the  scrotum  ^  are  chicHy  remarkable  for  the 
large  quantity  of  blood  liable  to  be  effused  beneath  the  skin.  When 
the  contusion  is  severe,  and  the  extravasation  considerable,  inflam- 
mation sometimes  arises  and  even  terminates  in  suppuration.  All 
the  treatment  required,  if  the  testicles  have  escaped  injury,  is  rest, 
support  with  a  bandage  or  pillow,  and  a  lotion  of  muriate  of  am- 
monia, or  a  ])oiiltice  of  oatmi'al  and  vinegar. 

2.  Lacerations  of  the  scrotum  -  though  formidable  in  appear- 
ance, usually  terminate  favorably;  there  is  no  ha?morrhage,  but, 
owing  to  the  contractile  nature  of  the  integuments,  the  wound  gapes 
and  the  testicles  protrude.  Cleanse  the  wound  with  carbolized 
water,  remove  coagula,  return  the  testicles,  and  close  the  wound 
with  sutures  and  adhesive  plaster;  proti-ct  the  parts  from  urine  by 
oiled  silk,  secure  rest,  and  the  application  of  cold. 

3.  Diffuse  inflammation  of  the  scrotum  *  occurs  in  two  forms. 
(1.)  The  mild  form  begins  as  a  light  erythema  and  terminates  favor- 

1  J.  Leidv.  2  T,  B.  Curling. 

35 


540  OPERATIVE  SURGERY. 

ably  under  gentle  antiphlogistic  treatment.  (2.)  The  more  scA'ere 
form  runs  a  rapid  and  dangerous  course  and  tends  quickly  to  mortifi- 
cation, with  typhoid  symptoms;  it  attacks  persons  of  a  cachetic  habit 
and  broken  down  constitution.  The  treatment  is  prompt  incisions 
into  the  distended  connective  tissue  to  relieve  tension;  haemorrhage 
must  be  prevented  by  filling  the  wounds  with  dry  lint;  carbolized 
water  dressings  should  then  be  applied,  or  light  poultices.  The 
general  treatment  must  be  actively  tonic  and  stimulating. 

4.  Mortification  of  the  scrotum  ^  is  the  result  of  the  preceding 
inflammation  or  of  ininary  extravasation.  This  sloughing  is  not  free 
from  danger,  but  in  general  the  extension  of  gangrene  may  be  ar- 
rested by  yeast  poultices,  and  thorough  cleansing  of  the  parts  with 
carbolic  solution,  combined  with  tonics.  Fortunately  there  is  no 
part  of  the  body  in  which  the  reparative  efforts  are  more  remark- 
able after  extensive  mortification;  even  when  the  whole  scrotum  and 
part  of  the  integument  of  the  penis  have  sloughed  away,  granula- 
tions have  rapidly  sprung  up  from  the  exterior  of  the  tunica  vagina- 
lis and  investments  of  the  cords,  cicatrization  has  advanced  from 
the  surrounding  skin,  and  the  testicles  and  spermatic  cords  have 
become,  in  time,  invested  with  a  new  covering  adequate  to  their  pro- 
tection. 

5.  Elephantiasis  of  the  scrotum  is  a  disease  peculiar  to  hot 
climates.  It  commences  as  a  hard  kernel  under  the  skin,  usually  at 
the  bottom  of  the  left  side  of  the  scrotum;  as  it  spreads  in  all  direc- 
tions, the  skin  over  it  becomes  thickened  and  indurated,  and  appears 
furrowed,  wrinkled,  and  glandular;  the  lower  part  of  the  abdomen 
is  elongated  by  the  traction  of  the  skin;  for  the  same  reason,  the 
penis  diminishes  in  length.^ 

In  the  later  stages  the  ruptured  lymphatics  allow  lymph  to  transude  from 
their  extremities;  or  walls  which  forms  crusts;  the  tumor  becomes  altered  in  ap- 
pearance aud  form,  being  smooth  in  contact  with  the  thighs,  and  narrow  above 
where  it  is  attached  to  a  sort  of  stalk,  and  large  below,  descending  sometimes 
below  the  knee.^ 

Removal  of  the  mass,  when  it  becomes  a  great  inconvenience, 
must  be  practiced.  As  expedition  is  of  the  greatest  moment,  the 
question  of  preserving  the  penis  and  testicles  must  first  be  positively 
determined.^  The  penis  may  generally  be  dissected  out  and  saved,  Intt 
when  the  tumor  exceeds  fifty  pounds  in  weight,  the  testicles  should 
not  be  saved.*  The  elastic  bandage  should  first  be  applied  to  the 
mass  and  firmly  fastened  around  the  pedicle  and  hips.  The  penis 
should  first  1)6  dissected  out  from  the  front  of  the  tumor  and  then  its 
pedicle  is  to  be  divided  by  rapid  strokes  of  the  amputating  knife, 
the  spermatic  cords  being  seized  to  prevent  retraction ;  if  the  gen- 
1  T.  B.  Curling.  2  Pniner.  ^  Kaposi.  *  Esdaile. 


THE   TESTICLES. 


547 


ital  organs  .are  preserved,  flaps  nuut  be  formed,  one  in  front  to 
cover  tlie  penis,  and  two  laterally  to  invest  the  testes;  liaMnorrhace 
must  be  arresti-(I,  during  the  oj)eration,  by  pressure  with  dry  sponges.^ 
The  after  treatment  is  that  of  all  large  wounds  of  integument,  the 
object  being  to  secure  prompt  union. 

6.   Varicocele  residts  from   a  varicose  state  of  the  veins  of  the 
spermatic  cord,  resulting  in  an  enlargement  of  its  tissues,  forming  a 

pendulous    mass,    which    becomes    a 
source  of  inconvenience.      The  early 
treatment  is  support   by  means  of  a 
suspensory  bag.     If   the   mass   becomes  a 
source  of  inconvenience,  the  varicose  veins 
of    the   cord   may   be    obliterated,    or   the 
mass  may  be  excised.      To   avoid  hajmor- 
rhai;e  the  clamp  should  be  used  as  follows: 
Draw  the  scrotum  between  the  blades  of  a 
serrated   clamp-    (Fig.    5G2),    until   the    requisite 
amount  is  inclosed;   turn  the  screw c,  and  approxi- 
mate the  blades  so  as  to  firmly  compress  the  in- 
closed tissues;  with  one  sweep  of  the  knife  remove 
the   redundant   portion    near    the   clamp;    sutures 
should  now  be  introduced  thickly  through  the  two 
flaps  and  firmly  tied,  when  the  clamp  may  be  re- 
moved, or  it  may  be  retained  partially  loosened. 

7.  Cancer  of  the  scrotum,  epithelial,^  is  gen- 
erally developed  as  a  small  pimple,  or  warty  ex- 
crescence, which  often  remains  for  months  or  years 
without  undergoing  any  change;  there  may  be  one 
wart,  or  two  or  three;    after  a  time  it  be- 
comes soft,  excoriated,  and  red,  and  exudes 
*^~*Xi3J^^  C  a   thin   discharge,  which  dries  as  a   scab; 
Fig.  562.  ulceration  follows,  characterized  by  an  in- 

durated base  with  elevated  edges,  and  an  irregularly  excavated  sur- 
face. There  is  no  effectual  remedy  but  the  knife,  and  greater  suc- 
cess attends  removal  than  similar  operations  on  other  parts.  The 
mass  sliould  be  removed  by  two  elliptical  incisions.^  If  inguinal 
glands  are  involved,  they  may  be  successfully  extirpated. 

8.  Hydrocele  is  an  accumulation  of  fluid  in  the  sac  of  the  tunica 
vaginalis,  and  is  caused  by  any  condition  which  stimulates  that 
membrane  to  over-secretion.  It  commences  at  the  lower  part  of  the 
scrotum  and  gradually  extends  upwards,  and,  when  well  marked,  the 
tumor  is  tense,  transparent,  and  fluctuating,  has  a  smooth  and  uni- 
form surface;  the  testicle  is  not  defined,  but  the  spermatic  cord  can 
1  T.  B.  Curling.  2  m.  H.  Henry.  »  Sir  J.  Paget. 


548  OPERATIVE  SURGERY. 

be  ti'aced  to  the  swelling;  ^  if  the  hydrocele  is  old  the  walls  may  be 
so  thick  that  the  transparency  is  lost.  The  hypodermic  syringe 
should  be  used  in  all  doubtful  cases.  The  palliative  treatment  is 
evacuation  of  the  fluid  by  puncture,  which  may  be  done  with  the 
bistoury  or  trocar;  the  puncture  should  be  made  a  little  below  the 
centre  of  the  anterior  part.  Grasp  the  tumor  in  the  left  hand,  the 
anterior  surface  being  uncovered;  avoiding  veins,  puncture  with  the 
instrument  inclined  slightly  upwards  and  backwards,  taking  care  not 
to  penetrate  so  deeply  as  to  wound  the  testicle.  The  radical  treat- 
ment consists  in  injections  of  tr.  ioiline;  or,  incision,  which  is  best 
performed  as  follows:  ^  Shave  the  parts  thoroughly  and  wash  with  a 
solution  of  carbolic  acid;  under  the  carbolic  spray  make  an  incision 
from  the  external  ring  to  the  base  of  the  scrotum;  wash  out  the  sac 
with  a  three  per  cent,  solution  of  carbolic  acid;  secure  bleeding  ves- 
sels with  cat-gut  ligatures;  stitch  the  edges  of  the  tunica  vaginalis  to 
the  skin  with  the  finest  silk  sutures,  the  wound  remaining  open;  if  the 
edges  of  the  wound  are  so  thick  as  to  make  it  deep,  insert  a  drainage 
tube;  bandage  the  scrotum  with  eight  to  ten  thicknesses  of  antiseptic 
gauze;  lay  a  mass  of  gauze  over  the  genitals,  with  an  opening  for 
the  penis,  so  as  to  cover  the  groin  and  lower  part  of  the  abdomen, 
and  bind  it  on  with  antiseptic  gauze  bandages;  leave  the  dressings 
on  three  or  four  days,  when  the  cavity  will  be  obliterated  by  adhe- 
sion. 

II.    THE  SPERMATIC  CORD. 

The  constituents  of  the  cord  are  the  excretory  duct,  blood  vessels, 
lymphatics,  nerves,  and  cremaster  muscle;  it  extends  from  the  in- 
ternal abdominal  ring  downward  to  the  back  part  of  the  testicle.^ 

1.  Varicose  veins  of  the  cord  are  more  properly  considei'ed 
under  the  Diseases  of  Veins. 

2.  Haeniatocele  of  the  cord  results  from  rupture  of  a  spermatic 
vein  during  violent  and  sudden  exertion,  or  from  contusion.  It  may 
be  diifuscd  or  circumscribed.  When  diffused,  it  has  been  mistaken 
for  hernia,  but  a  careful  study  of  the  symptoms  will  determine  the 
difference,  or  an  exploratory  incision  may  be  made.  The  encysted 
variety  is  rare,  and  cannot  certainly  be  diagnosed,  except  by  punc- 
ture. The  treatment  should  at  first  be  cold  applications;  if  the  tumor 
does  not  disappear,  but  inflames,  or  is  a  source  of  annoyance,  its 
contents  should  be  removed,  antiseptically,  by  incision. 

2.  Hydrocele  of  the  cord^  consists  in  the  collection  of  fluid  in 
some  part  of  the  cord;  the  sac  is  thin,  and  is,  in  most  instances, 
an  unobliterated  portion  of  the  canal  of  the  tunica  vaginalis,  which 
has  l)econie  distended  by  an  accumulation  of  fluid  in  it  ;  the  tumor 
is  usually  oblong,  transparent,  and  may  exist  as  an  independent  cyst. 

1  T.  B.  Curling.  2  K.  Yolkinaii.  3  j.  Leidy.  ■•  G.  M.  Humphrey. 


THE   TESTICLES.  549 

The  treatment  is  the  application  of  tr.  iodine,  with  pressure,  which 
freciucntly  inchu-es  aI)sorptlon;  if  the  fhiid  is  encysted,  it  may  Ik- 
evacuated  by  puncture  and  the  sac  obUterated  by  an  injecliun  of  tr. 
iodine. 

III.    THE  TESTIS. 

The  gland  consists  of  two  parts,  the  ej)ididymis  and  the  body;  the 
epididymis  is  the  continuation  of  the  spermatic  cord,  and  is  closely 
applied  to  the  posterior  part  of  the  body;  the  body  consists  of  the 
glandidar  structure,  invested  by  a  dense  white  membrane,  the  tunica 
albuginea. 

1.  Heematocele  ^  consists  of  an  effusion  of  l)lood  either  into  the 
cavity  of  the  tunica  vaginalis,  from  a  vessel  ruptured  by  a  blow,  or 
into  a  hydrocele  or  cyst;  when  the  enlargement  immediately  follows 
injury,  and  the  parts  are  discolored,  the  diagnosis  is  easy;  but  when 
the  affection  is  more  chronic  and  the  ecchymosis  has  jiassed  away 
and  been  forgotten,  the  diagnosis  is  often  very  difficult.  Apply  cold 
to  arrest  bleeding  and  promote  absorption;  if  the  accumulation  re- 
main, and  create  irritation  or  inconvenience,  puncture  antiseptically 
and  evacuate  the  blood;  if  suppuration  occur,  open  the  cavity, 
cleanse  it  with  carbolic  acid  solution,  and  apply  dressings  as  for  an 
02)en  abscess. 

2.  Epididymitis  is  caused  by  injuries,  or  by  irritation  in  the  ure- 
thra, especially  about  the  orifices  of  the  seminal  duels.  It  commen- 
ces with  tenderness  and  swelling  of  the  lower  and  posterior  part  of 
the  epididymis;  the  swelling  extends  until  the  whole  epididymis  is 
involved,  serum  and  lymph  being  infiltrated  into  the  connective  tis- 
sue ;  tlie  pain  is  often  very  severe  in  the  early  stages,  being  dull, 
heavy,  and  sickening.^  On  examination,  the  line  of  division  between 
the  soft  testicle  in  front  and  tlie  hard  inflamed  epididymis  behind, 
can  be  readily  traced.  The  treatment  should  depend  upon  the  se- 
verity of  the  disease.  In  the  gonorrheal  form,  all  efforts  to  arrest 
the  discharge  must  be  abandoned.  In  gcMieral,  direct  the  recumbent 
position,  and  support  the  parts  in  a  suspender. 

Double  a  handkerchief  so  as  to  form  a  triangle,  the  middle  of  the  base,  to 
which  a  piece  of  doulile  tape  lias  been  sown,  beiiij;  applied  to  the  perineum,  and 
the  extremities  of  the  liandkerchief  carried  forward  and  attached  in  front  to  a 
band  round  the  waist,  whilst  the  ends  of  the  tape  being  secured  to  the  band 
behind  prevent  the  handkerchief  slipping  forwards.- 

In  mild  cases  it  is  often  sufficient  to  secure  rest,  elevation  of  the 
organ  with  spirit  lotions,  or  iiot  poultices  and  saline  cathartics.  In 
acute  cases,  apply  a  tobacco  poultice  as  follows:  Mix  a  paper  of  any 
fine-cut  tobacco,   §1.  in  j.x.  of  hot  water;  raise  it  to  a  boiling  point 

1  G.  M.  Humphrey.  2  x.  13.  Curling. 


550 


OPERATIVE  SURGERY 


while  stirring  it  briskly,  and  add  ground  flax  seed,  until  the  proper 
consistence  of  a  poultice  is  obtained.^  In  obstinate  cases,  apply  six 
to  twelve  leeches  in  the  course  of  the  cord  above  the  inflamed  part.^ 
Ice  is  sometimes  useful  when  the  inflammation  is  severe,  but  it  must 
be  so  ajiplied  and  maintained  as  to  preserve  a  uniform  low  tempera- 
ture of  the  parts.  When  the  inflannnation  subsides  there  often  re- 
mains considerable  enlargement,  which  may  be  reduced  by  uniform 
strapping. 

The  patieut  being  placed  in  the  recumbent  position,  with  the  testicle  raised, 
is  to  remain  there  three  or  four  minutes,  in  order  to  allow  the  vessels  of  the 
gland  to  become  as  empty  as  possible.     The  parts  are  to  be  shaved;  and  some 


ipfi 


Fig.  563. 


adhesive  plaster  or  chamois  leather  must  be  cut  into 
strips,  about  three  quarters  of  an  inch  in  width,  and 
eight  or  nine  inches  in  length.  The  opposite  testicle 
and  side  of  the  scrotum  being  drawn  away  from  the 
diseased  one,  so  as  to  render  the  integuments  of  the 
latter  quite  tense,  the  first  strap  is  to  be  placed  circu- 
larly (Fig.  503)  around  the  cord,  just  above  the  testi- 
cle, as  tightlv  as  the  patient  can  bear  it;  a  strip  of  lint 
may  be  placed  beneath  the  edge  of  the  plaster  to  pre- 
vent its  irritating  tiie  scrotum;  the  second  strap  is  t« 
be  placed  in  an  opposite  direction,  from  behind  for- 
wards, at  the  side  of  the  testicle,  near  the  septum;  the 
third  strap  is  to  be  applied  below  the  first,  so  as  partly 
to  overlap  it;  and  the  fourth  in  like  manner,  internal 
to  the  second,  and  so  on  until  the  straps  meet,  and  the 
whole  of  the  testicle  is  covered  and  evenly  compressed. 


3.  Syphilitic  orchitis,  inflammation  of  the  gland  from  syphilitic 
poison,  occurs  in  the  tertiary  stage  of  that  disease. 

The  disease  appears  in  two  forms.3  The  first  is  simply  inflammatory;  the 
mischief  sets  out  from  the  interstitial  structures  in  a  hyperplastic  growth  of 
young  connective  tissue,  followed  by  fibroid  condensation;  the  white  fibrous 
bands  may  be  distinguished  by  the  naked  eye,  conoidal  in  shape,  determined  by 
the  lobular  segmentation  of  the  organ;  finally,  nothing  is  seen  beyond  a  mass 
of  white  fibroid  tissue,  all  trace  of  the  old  divisions  of  the  gland  having  disap- 
peared with  the  tubuli  seminiferi.  The  formation  of  gummata  is  to  be  regarded 
as  only  a  further  specialization  of  the  morbid  process  ;  several  nodules  of  the 
size  of  a  cherry-stone  are  usually  scattered  through  the  fibroid  mass;  the  specific 
changes  set  out  from  a  proliferation  of  the  corpuscular  elements  of  the  con- 
nective tissue  followed  b}'  a  fatty  degeneration. 

The  enlargement  of  the  testis  usually  takes  place  gradually  and 
without  pain,  except  perhaps  along  the  cord,  and  is  generally  dis- 
covered by  accident;  it  may  be  perfectly  smooth,  and  hard  as  wood, 
but  usually  is  nodular,  and  insensitive  on  pressure. ^  The  treatment 
should  be  with  mercury  and  iodide  of  potassium,  as  in  the  following 

1  Van  BurL'u  and  Keyes.  2  x.  13.  Curling.  3  £.  Kimlfleisch. 


THE   TESTICLES.  551 

formula :  potas.  iodid.  3i.,  hydrarg.  bithlor.  jjr.  ps.,  syr.  sarzie,  tr. 
cinch.  CO.  aa.   ^'j-  ^^-i  ^'^^^  o"*i  teaspoonful  three  times  daily. ^ 

If  the  surface  is  broken  and  a  fungus  appears,  it  sliould  not  lie  treated  by  ex- 
cision but  by  strapping  and  nitrate  of  silver;  removal  of  tiie  enlarf^ed  organ 
should  not  be  attempted  until  a  thorough  course  of  anti-syphilitic  treatment  has 
been  tried  faithfully,  and  with  large  doses  of  iodiile  of  potassium.2  The  testis 
should  at  all  times  be  properly  supported  by  a  suspensory  bandage. 

4.  Tubercles  of  the  testis  consist  of  certain  cheesy  nodules  of 
considerable  l)ulk  and  more  or  less  globular  vsliape,  commonly  multiple 
for  a  time,  but  finally  tliey  coalesce  to  form  a  single  mass,  remark- 
able for  its  peculiar  elasticity,  which  it  retains  until  a  central  soften- 
ing leads  to  an  abscess ;  this  tends  to  burst  and  give  rise  to  the  well- 
known  fistula  which  is  remarkable  for  its  extreme  chronicity,  and 
occasional  discharge  of  sodden  shreds  of  seminiferous  tubuli  through 
it.*  Suppuration  rarely  occurs  in  children.*  The  treatment  should 
be  largely  hygienic,  as  exercise  in  the  open  air  and  nutritious  food; 
quinine,  iron,  and  cod-liver  oil  are  the  most  useful  remedies;  the  tes- 
tis must  always  be  supported.  Castration  is  required  only  in  ex- 
treme cases,  and  must  not  be  performed  if  there  are  signs  of  ad- 
vanced disease  in  the  lungs.* 

5.  Sarcoma^  in  all  its  principal  varieties  finds  a  favorite  seat  ia 
the  testicle;  the  tumor  almost  always  contains  not  only  all  the  chief 
varieties  of  sarcoma,  but  all  the  histioid  formations  which  are  met 
with  in  the  sarcomata  as  well;  cartilage,  mucous  and  connective  tis- 
sue, striped  and  unstriped  muscle,  enter  more  or  less  into  tlie  composi- 
tion of  the  sarcomata  of  this  organ ;  these  frequent  combinations  intro- 
duce an  element  of  great  variety  into  the  structure  of  the  sarcomata 
of  the  testicle,  and  this  is  rendered  more  manifold  by  the  frequent 
occurrence  of  cysts  in  their  interior.  The  growth  is  slow,  usually 
painless,  oval,  and  smooth.     The  treatment  is  removal  of  the  gland.* 

6.  Caucer  of  the  soft  variety,  fungus  ha?matoides,  is  not  easily 
distinguished  from  soft  sarcoma;  it  is  the  only  form  which  jn-imarily 
attacks  the  testicle.  It  develops  rapidly,  is  uneven,  with  hard  and 
soft  spots,  the  pain  is  often  severe,  and  the  tumor  may  attain  to  an 
inunense  size.     Early  extirpation  is  the  only  remedy. 

7.  Castration*  is  an  operation  simple,  easy  of  performance,  and 
nearly  free  from  danger.  Shave  the  hair  from  the  pubes  and  scro- 
tum; the  patient  being  properly  placed,  and  under  ether,  make  an 
incision  from  about  iialf  an  inch  below  the  external  ring  along  the 
front  of  the  tumor  to  the  bottom  of  the  scrotum;  divide  the  envelopes 
of  the  cord  and  testicle,  the  layers  of  the  thickened  fascia,  and  the 
cremaster  muscles  nearly  as  high  as  the  ring ;  expose  the  spermatic 

1  V.  Molt.      -  Van  lUiieii  and  Keves.      3  K.  Uindtlcisch.      *  T.  B.  Curling. 
5  T.  Billroth. 


552  OPERATIVE  SURGERY. 

cord,  and  detach  it  from  the  surrounding  parts;  if  the  division  is  to 
be  made  high  up,  pass  a  very  stout  double  ligature  through  it,  tie 
firmly  each  half,  and  sever  the  cord  below;  if  the  divis;ion  is  near 
the  testis,  grasp  the  cord  firmly  with  the  fingers,  cut  it  below,  and 
tie  the  arteries  separately,  first  the  spermatic  artery,  and  next  the 
artery  of  the  duct;  the  gland  is  next  to  be  removed,  partly  by  tear- 
ing it  from  its  connections,  and  all  bleeding  vessels  tied;  tlie  wound 
should  be  closed  by  sutures,  except  at  the  lowest  angle;  a  drain-tube 
should  be  introduced. 


CHAPTER    LI. 

THE   PROSTATE   GLAND. 

This  body  ^  is  situated  between  the  neck  of  the  bladder  and  the 
triangular  ligament,  and  surrounds  the  first  portion  of  the  urethra. 

It  is  usually  from  one  to  one  and  a  half  inches  in  length  and  breadth,  and 
about  three  fourths  of  an  inch  in  thickness;  its  apex  adheres  to  the  triangular 
ligament,  and  its  notched  base  encircles  the  neck  of  the  bladder;  the  lateral 
portions  form  the  lateral  lobes,  and  the  isthmus  which  unites  them  beneath  the 
neck  of  the  bladder  is  called  the  middle  lobe. 

1.  Injuries  of  the  prostate  usually  occur  during  operations  involv- 
ing the  bladder  and  urethra.  They  can  only  be  treated  by  rest  and 
cleanliness;  if  urinary  extravasation  occurs,  or  abscess  forms,  free 
incisions  are  necessary  to  prevent  further  accumulations. 

2.  Hypertrophy^  of  the  prostate  takes  two  forms;  in  the  less 
common  variety  there  is  a  uniform  enlargement  of  the  organ  in  all 
its  dimensions  and  a  marked  increase  in  its  density,  due  to  the  pres- 
ence of  an  exceedingly  tough,  inelastic,  whitish,  fibrous  tissue  which 
permeates  the  entire  gland;  the  muscular  bundles  are  all  in  a  state  of 
overgrowth,  while  the  gland-tubuli  waste  and  disappear.  In  the 
more  usual  form  there  are  discrete  nodules  in  the  substance  of  the 
gland,  rounded  in  form,  containing  both  glandular  and  muscular  ele- 
ments; the  manifold  varieties  of  external  form  presented  by  the 
hypertrophied  prostate,  the  implication  now  of  its  right,  now  of  its 
left  lateral  lobe,  and  then  of  its  middle  lobe,  the  immense  variety  of 
distortions  and  dislocations  to  which  the  prostatic  part  of  the  urethra 
may  be  subjected,  are  phenomena  easily  explained  by  tlte  lack  of 
uniformity  in  the  distribution  and  rate  of  growth  of  the  nodules. 
The  first  effect  on  the  prostatic  urethra  is  increase  of  its  antero- 
posterior diameter,  with  diminution  of  its  lateral  or  transverse  diam- 
eter, the  canal  becoming  a  narrow  passage,  instead  of  one  which, 
when  distended,  is  of  about  equal  diameter  in  every  direction;  the 

1  J.  Leidy.  2  E.  Rindfleisch. 


THE  PROSTATE   (U.AND.  553 

lenjith  of  tlie  prostatic  urethra  is  also  materially  increased,  and  is 
often  tortuous;  the  natural  direction  also  deviates,  namely,  where 
the  median  portion  is  enlarged,  the  urethra  sud(h'nly  rises,  producing 
an  angular  curvature  in  j)lace  of  a  nearly  straight  line;  if  there  is 
also  enlargement  of  either  lateral  lobe,  the  lateral  direction  of  the 
canal  is  also  changed,  the  convexity  being  towards  the  large  lateral 
lobe. 

The  most  important  result  of  enlargement  is  ol)Struction  to  the 
flow  of  urine,  but  the  symptoms  not  unfrecjuently  exist  long  before 
the  real  cause  is  suspected  ;  there  is  more  frcfjuent  desire  to  pass 
water,  but  the  force  is  diminished;  a  disagreeable  sense  of  weight 
and  fullness  is  experienced  about  the  perineum;  cystitis  follows; 
then  pyelitis,  and  the  patient  is  finally  worn  out  with  sufTering.  But 
the  test  cliiedy  depended  upon  is  digital  examination  by  the  rectum, 
as  follows  :^  IMace  the  patient  on  his  back  on  a  couch,  with  his  knees 
drawn  up  and  separated  a  little;  standing  on  his  right  side,  introduce 
the  index  finger  of  the  left  hand  slowly  through  the  sphincter,  and 
when  two  phalanges  are  free  in  the  rectum,  define  the  size,  form,  and 
consistence  of  the  prostate;  then,  with  the  right  hand,  so  manage 
the  catheter  introduced  through  the  urethra  as  to  determine  the 
thickness  of  tissues,  and  the  direction  of  the  canal.  Now  withdraw 
the  finger,  and  explore  with  the  ordinary  catheter  ;  if  it  pass  as  usual, 
and  water  flows  at  the  depth  of  six  to  eight  inches,  the  evidence 
is  against  hypertrophy;  but  if  the  instrument  passes  nine  or  ten 
inches  and  no  urine  escapes,  and  the  handle  is  unusually  depressed, 
there  will  be  little  doubt  of  enlargement ;  a  prostatic  catheter  should 
now  be  used,  which  is  two  to  four  inches  longer,  with  a  larger 
curve,  and  the  direction  which  it  takes,  the  depth  at  which  water  be- 
gins to  flow,  and  other  facts  noted.  One  of  the  best  evidences  of 
hypertroj)hy  is  the  flow  of  urine  through  the  catheter,  ])assed  imme- 
diately after  the  patient  has  evacuated  the  bladder.^  The  only  oper- 
ative treatment  should  be  that  which  is  designed  to  obviate  the 
results.  This  is  done  by  completely  evacuating  the  bladder  at  least 
once  a  day  with  a  catheter.  As  a  rule,  the  catheter  should  not  be 
retained  long  in  the  urethra;  if,  however,  it  is  found  necessary  to 
procure  sleep  or  rest,  the  vulcanized  instrument  may  be  retained 
either  by  a  string  attached  to  its  external  extremity  and  fastened 
around  the  body  of  the  penis,  or  by  using  a  winged  catheter  (Fig. 
564).     All  forms  of  direct  medication  have  proved  useless. 

The  catheter  is  stretclicd  upon  the  stilet,  and  fastened  to  tlie  handle  ready 
for  introduction,  which  is  effected  as  follows  :  Suppose  the  catheter  a  No.  8 
guajje;  insert  the  stilet  and  draw  the  India-rubber  upon  it  towards  the  handle, 
until  the  sI/a'  of  the  catheter  is  reduced  to  a  No.  4  ;  fix  it  in  that  situation  by 

1  Sir  H.  Thompson.  2  r.  p.  Wgir. 


554 


OPERATIVE  SURGERY. 


tvins  a  piece  of  string  immediately  in  front  of  tlie  puckered  portion,  and  fas- 
ten it  to  the  hole  in  the  handle;  thus  the  calibre  of  the  catheter  is  reduced  one 
half,  and  will  easily  enter  the  bladder;  the  string  may  now  be  untied,  and  the 
catheter  will  resume  its  ordinary  size;  where  the  urethrals  sufficiently 
capacious,  the  catheter,  previous  to  being  used,  may  be  passed  into  a 
No.  12  silver  catheter  having  an  opening  at  the  end,  and  when  in  the 
bladder  the  silver  catheter  may  be  withdrawn. 


Fig.  564.1 


Great  difficulty  is  often  experienced  in  passing  a  catheter  through 
the  prostatic  urethra,  owing  to  its  irrcfrularities,  and 
many  modifications  of  catheters  have  been  made  to 
meet  these  peculiarities.    Of 


Fig.  565. 


these  the  most  useful  are  the 

single  (Fiu;.  5(5.5)'^  and  double 

elbow  catheters  (Fifz;.  566),''^ 

the    ends    of     which    keep 

closely  applied  to  the  roof  of  the  urethra.     In  some  cases  the  canal 

is  more  readily  traversed 
by  the  vertebrated  cathe- 
ter.3  In  very  tortuous  pas- 
sages a  prostatic  guide,* 
with  spiral  shaft  (Fig. 
568),  will  follow  the  de- 
FiG.  Ov.G.  vious  route  more  certainly 

than  even  the  vertebrated  catheter  (Fig.  567). 

The  prostatic  guide  consists  of  a  slight  steel  rod,  a  (Fig.  568),  eight  inches 

in  length,  upon 
which  is  screwed 
a  spiral  ribbon, 
B,  five  inches  in 
length.  The  un- 
ion is  strength- 
ened by  the  pro- 
jection of  the 
end  of  the  rod 
into  the  spiral, 
for  half  an  inch 

beyond  the  screw,  c.    This  spiral  ribbon  is  so  flexible  that  it  can  easily  be  made 
to  take  the  curve  of  the  urethra,  or  any  irregularity  in  its  course  which  may 

1  G.  Tiomnnn  &  Co.        2  A.  Mercier.         3  x.  R.  Squires.         ^  F.  N.  Otis. 
5  fcjtuhiiiianii,  Pfarre  &  Co. 


Fig.  567.5 


THE  PEXIS.  555 

present.  Its  small  size  may  make  it  capable  of  being  easily  introduced  into  a 
soft  rubber  catheter,  and  by  means  of  it  the  catheter  may  be  carried  down  and 
along  tiie  urethra  to  and  into  tlie  bladder,  following  any  deviation  in  the  course 
of  the  canal  which  may  be  present  from  prostatic  enlargiMUc-iit  or  other  causes. 


8 

Fig.  568. 


CHAPTER   LII. 

THE  PENIS. 

The  penis  is  composed  prinoipally  of  an  erectile  tissue  arranged 
in  masses  wliieh  occupy  three  long  and  nearly  cylindrical  compart- 
ments, namely,  two,  the  corpora  cavernosa,  placed  side  by  side, 
which  form  the  principal  part  of  the  organ,  and  the  corpus  spon- 
giosum, which  surrounds  the  canal  of  the  urethra;  it  is  attached  to 
the  pubic  arch  by  its  root,  and  in  front  ends  in  the  glans  which  is 
continuous  with  the  spongy  body;  the  integument  of  the  penis  is 
continued  from  that  of  the  pubes  and  scrotum  and  forms  a  simple 
investment  as  far  as  the  neck  of  the  glans,  where  it  is  doubled  up  in  a 
loose  cylindrical  fold  constituting  the  pivpuce.^ 

1.  Injuries  of  the  penis  occur  in  many  forms.  The  organ  may 
be  fractured  by  being  forcibly  bent  when  erect; '^  the  treatment  is 
cold.  Contusions  rarely  require  other  measures  than  such  as  prevent 
inflammation.  Wounds  are  to  be  treated  as  other  wounds,  care 
being  taken  to  prevent  urinary  infiltration  and  curvatures  in  cica- 
trization. 

2.  Phimosis  is  such  a  contraction  of  the  prepuce  that  the  glans 
cannot  he  uncovered;  in  the  normal  comlition  of  the  infant  the  pre- 
puce is  adherent  to  the  glans,  but  later  these  adhesions  are  broken 
down  and  the  prepuce  becomes  free.  If,  however,  there  is  inflam- 
mation excited  by  irritants,  as  accumulations  of  filth  under  the  pre- 
puce, these  adhesions  may  become  firm;  or,  the  orifice  may  become 
inflamed  and  so  dense  that  it  will  not  yield,  even  to  allow  the  free 
passage  of  urine.  The  affection  may  be  a  source  of  great  discom- 
fort in  children,  resulting  in  spasms  of  the  muscles  of  different  parts 
of  the  body,^  and  in  adults,  of  collections  of  filth  and  foul  matters. 
The  treatment  is  circumcision.  In  performing  this  operation  it  is 
important  to  seize  the  orifice  of  the  j)repuce  for  the  purpose  of  mak- 
ing suitable  traction  on  the  mucous  memhrane,  which  is  hut  sIiLrlitly 
elastic  compared  with  the  skin.     First  insert  a  well-oiled  probe  under 

1  Quain's  Anatomy.  ^  y.  Mott.  3  £,.  .\  Sayre. 


556 


OPERATIVE  SURGERY. 


Fig.  569. 


the  prepuce  and  sweep  the  surface  of  the  glans  to  break  up  adhe- 
sions ;  seize  the  orifice  of  the  prepuce,  at  opposite  points,  with  sliarp- 
toothed  forceps,  drawing  the  whole  forwards  until  the  mucous  mem- 
brane is  put  well  upon  the  stretch  (Fig.  569);  grasp  the  prepuce 

firmly  just  in  front  of  the  glans 
with  a  clamp,  or  forceps;  with 
the  bistoury  cut  away  the  jior- 
tion  anterior  to  the  clamp;  if 
the  prepuce  readily  retracts, 
the  angles  may  be  cut  away, 
and  the  mucous  and  skin  flajis 
united  by  a  number  of  fine  su- 
tures; if  the  prepuce  is  not  free, 
all  tightness  must  be  relieved 
by  an  incision  on  the  dorsum, 
or,  in  infants,  by  tearing  the 
tissues;  the  cut  mucous  membrane  must  be  attached  to  the  skin  by 
numerous  fine  sutures  beginning  at  the  raphe;  rest  and  water  dres- 
sings are  only  required  in  the  after  treatment.^  In  slight  cases  it 
may  be  sufficient  to  slit  up  the  pre- 
puce on  the  dorsum,  and  attach 
the  edges  as  before.  If  there  is  a 
contracted  prepuce,  after  the  ex- 
cision 2  slit  up  the  skin  three  to  six 
lines  on  the  dorsum  of  the  penis 
(Fig.  570),  trim  the  corners  round, 
5,4,  G  (Fig.  571),  incise  the  mucous 
membrane  2,  1,  3  (Fig.  571),  adjust 
the  point  1  to  4,  2  to  5,  and  3  to  6, 
•with  sutures,  and  the  rest  of  the  circumference 
numl)er  to  hnld  them  in  position.^ 

3.  Paraphymosis  ^  occurs  when  the  prepuce  is  withdrawn  behind 
the  glans  and  cannot  be  brought  forward;  the  prepuce  forms  a  con- 
stricting band  around  the  corona,  which  is  followed  by  swelling  of 
the  glans  and  oedema  of  the  prepuce.  The  treatment  is  prompt 
reduction.  If  the  swelling  is  slight,  and  without  strangulation,  re- 
duction may  be  effected  by  the  methods  given  below,  or  by  strips  of 
rubber  plaster  applied  longitudinally  from  the  middle  of  the  penis 
on  one  side  over  the  apex  of  the  glans  to  the  middle  of  the  penis 
opposite,  the  meatus  being  left  uncovered,  until  the  organ  is  covered. 
If  there  is  dangerous  strangulation  shown  b}'  the  dark  color  of  the 
glans,  and  great  oedema  of  the  prepuce,  reduction  is  more  difficult, 
but  may  be  aided  by  employing  cold,  and  puncture  of  oedematoua 
1  Van  Buren  and  Keyes.  2  £,  L.  Keyes.  3  l.  a.  Stimson. 


Fig.  570. 


by 


Fig.  571. 
a   sufficient 


THE  PENIS. 


557 


^&M\y 


r/^^i 


parts.     Reduction  is  effected  as  follows:    Give  an  anaesthetic;  seize 

the  penis  beliind  tlie  strictured  j)re- 
puce,  between  tlie  index  and  mid- 
dle  fingers  of  both   hands,   placed 
either   side    (Fig.    572),    make 
pressure  with  the  thumbs  on  both 
of  the  glans,  in  such  direction 
as  to  compress  the  glans 
laterally,     rather    than 
from    before     backward, 
and    at    the    same   time 
pull   the    strictured    por- 
tion of  the   prepuce  for- 
ward;   the    manipulation 
is  designed  to  re(hice  the 
Fig.  572.  glans  by  compression,  and 

pull  the  stricture  over  the  glans,  and  not  to  push  the  glans  through 
the  stricture. 

Or,  the  penis  may  be  encircled  with  one  hand  (Fig.  573),  while  compression 

is  made  with  the  thumb  and  fin- 
ger as  before.  Or,  place  tiie  index 
and  middle  finger  of  the  right  hand 
longitudinally  along  the  lower  sur- 
face of  the  penis,  and  the  pulp  of 
the  thumb  on  the  dorsum  of  the 
ghms  and  the  oedematous  ridge  in 
front  of  the  point  of  stricture  (Fig. 
574);  by  firm  pressure  crowd- 
ing down  the  swollen  mucous 
membrane  of  the  prepuce, 
endeavor  to  insinuate  the  end 
of  the  thumb  nail  under  the 
stricture;  succeeding  in  this, 
grasp  the  penis  and  the  two  fingers 
of  the  right  hand  beneath,  in  a  cir- 
cular manner,  with  the  left  hand, 
and  draw  the  strictured  point  up  over 
the  thumb  nail,  and  by  simultaneous 
traction  of  both  hands  replace  the 
prepuce. 1  If  a  prolonged  and  care- 
ful attempt  at  reduction  fails  the 
strictured  point  must  be  divided  as  follows:  Introduce  a  tenotomy  knife  flat- 
wise along  the  sheath  of  the  penis,  subcutaneously,  under  the  stricture,  and  cut 
outward  until  all  tension  is  removed;  or,  a  simple  incision  may  be  made  down 
to  the  sheath  of  the  penis.  The  after  treatment  consists  of  cleanliness  and  syr- 
inging the  preputial  cavity  with  carbolized  water. 

4.  Cancer  of  the  epithelial  variety  most  frequently  aflfects  the 

1  A.  Mercier. 


558 


OPERATIVE  SURGERY 


Fig.  574. 


penis;  it  may  occur  on  the  prepuce,  but  usuallj-  it  appears  on  the 
glans  as  a  firm,  warty  elevation,  having  a  broad  base;  it  slowly  in- 
creases, without  pain,  at  first  covered  with  a 
more  or  less  thick  cuticular  crust,  which  leaves 
a  bleeding  surface  when  removed;  in  its  prog- 
ress it  destroys 
the  glans,  opens 
the  urethra,  in- 
volves the  pre- 
puce, finally  af- 
fects the  glands 
of  the  groin, 
and  proves  fa- 
tal, by  irritation, 
and  discharges 
from  progres- 
sively spreading 
ulceration.^  The 
treatment  is  ex- 
tirpation. If  the  prepuce  alone  is  affected,  circumcision  must  be 
performed.  If  the  glans  is  slightly  affected,  the  diseased  jiart 
may  sometimes  be  excised  without  injuring  the  urethra.  In  general, 
amputation  through  the  anterior  part  of  the  penis  is  performed,  as 
follows :  Inclose  the  organ  at  its 
root  in  a  clamp  -  like  that  used  for 
haemorrhoids  (Fig.  5  75),  or  apply 
a  tape  to  pre- 
vent haemor- 
rhage; divide 
the  organ  at 
a  stroke,  the 
skin  being 
slightly  r  e- 
traeted,     ow-  Fig.  575.3 

ing  to  its  tendency  to  excessive  retraction ;  ligate  all  the  vessels, 
then  slit  the  urethra  above  slightly  and  below  to  the  extent  of  half 
to  two  thirds  of  an  inch  to  render  the  new  opening  patulous  after 
cicatrization;  now  carefully  connect  the  urethral  margin  to  that  of 
the  skin  by  many  fine  sutures,  commencing  at  the  lower  angles. 
Apply  cold  dressings. 

If  the  disease  involve  the  penis  at  a  higher  point,  it  may  be  necessary  to  ex- 
tirpate the  organ  altogether,  as  follows'':  The  patient  having  been  etherized. 


1  G.  M.  Humphrey. 
4  J.  W.  S.  GOLLEY. 


-  W.  Bodenhamer. 


3  G.  Tiunianii  &  Co. 


THE   OVARIES.  559 

make  a  cun'ilinear  incision  on  either  side  of  the  root  of  the  penis,  be^jinnin;^  in 
the  median  line,  at  ahout  one  inch  and  a  half  above  the  level  of  the  pubes,  and 
ending  a  little  below  the  peno-scrotal  junction;  this  elliptical  wound  exposes 
the  cavernous  bodies,  wliicli  may  be  transfixed  by  a  larj^e  knitting-needle,  the 
ends  of  which  rest  on  either  groin  and  serve  to  prevent  retraction  of  the  stump; 
pass  a  smaller  knitting-needle  across  and  through  the  urethra  on  the  same  plane 
as  tlie  first  needle,  and  with  '  serrated  scissors  sever  the  penis  at  a  point  about  one 
eighth  of  an  inch  anteriorly  to  the  needles;  four  or  live  vessels  require  the  liga- 
ture besides  those  of  the  subcutaneous  tissue,  which  are  secured  in  tlie  pubic 
and  scrotal  portions  of  the  wound;  the  mouth  of  the  urethra  is  easily  found  on 
account  of  the  needle,  and  a  grooved  stalT  is  introduced  through  it  into  the 
bladder;  jilunge  a  scalpel  into  the  centre  of  the  perineum  and  into  the  groove 
of  the  staff,  and  divide  all  the  tissues,  including  the  skin,  at  one  sweep  of  the 
knife  from  behind  forward  and  from  below  upward;  the  urethral  cut  is  about 
an  inch  and  a  riuarter  in  length,  including  half  of  the  bulb,  and  the  cutaneous 
wound  three  inches;  detach  the  urethra  from  the  cavernous  bodies,  slit  it  longi- 
tudinally, and  stitch  its  free  extremity  to  the  upper  commissure  of  the  perineal 
wound  and  its  edges  to  the  skin. 


THE  FEMALE  ORGANS. 


CHAPTER   LIII. 

THE   OVARIES. 

These  bodies  correspond  to  the  testicles  of  the  male;  they  are 
somewhat  flattened  and  oral,  and  are  placed  on  each  side  of  the 
uterus,  at  the  back  of  the  broad  ligament,  and  are  cnvclojjed  in  its 
posterior  membranous  layer;  each  ovary  is  free  on  its  two  sides,  an<l 
along  its  posterior  border,  which  has  a  convex. outline,  but  is  attached 
by  its  anterior  border.'^ 

I.     INFL.VMMATION. 

Ovaritis  may  become  a  powerful  disturbing  element  in  the  physi- 
cal constitution  of  woman  ;  in  some  cases  the  ovarian  pain  and  ex- 
acerbation of  sufferings  at  the  menstrual  epoch  are  almost  unbear- 
able, in  others  it  causes  such  violent  disturbance  of  the  vascular  and 
nervous  systems  that  life  is  jeoparded;  occasionally  it  terminates  in 
epilepsy  or  insanity,  and  ultimately  in  death. ^  In  these  extreme 
cases  extirpation  of  the  ovaries  has  been  performed  with  success. 
The  mortality  is  very  great,  being  eleven  deaths  in  thirty-six  cases.* 
The  object  sought  is  the  artificial  production  of  the  menopause,  or 

1  Richardson's.         2  Quain's  Anatomy.         *  J.  M.  Sims.         ■*  Eujjelman. 


560  OPERATIVE  SURGERY. 

the  cessation  of  menstruation.^     In  this  view  the  question  of  extirpa- 
tion has  been  determined  as  follows  :  ^  — 

(1.)  In  case?  of  amenorrhoea  where  there  is  no  uterus,  or  only  the  rudiments 
of  one,  or  where  there  is  an  incurable  atresia  uteri,  and  the  menstrual  molimen 
produces  such  violent  disturbance  of  the  whole  system  as  to  destroy  health  and 
endanger  life,  the  removal  of  the  ovaries  is  the  onh'  means  of  permanent  relief. 
(2.)  In  cases  of  prolonged  physical  and  mental  suffering  attended  with  great 
nervous  and  vascular  excitement  produced  by  perturbed  menstrual  molimen, 
whether  menstruation  be  absent,  scanty,  or  otherwise,  this  operation  is  justifi- 
able after  all  the  usual  remedies  fail  to  relieve.  (3.)  In  cases  of  incipient  insan- 
ity and  of  epilepsy  depending  upon  ovarian  and  uterine  disease  this  operation 
is  justifiable  after  all  other  remedies  have  failed  to  cure.  (4.)  In  cases  of  fibroid 
tumors  of  the  uterus  attended  with  incurable  hfemorrhages  that  endanger  life, 
when  the  tumors  cannot  be  safelj'  enucleated  and  removed,  this  operation  may 
be  resorted  to  with  the  hope  of  arresting  the  bleeding  and  the  prospect  of  dimin- 
ishing the  tumors.  (5.)  In  cases  of  chronic  pelvic  cellulitis  and  of  recurrent 
hematocele,  when  the  attacks  are  traceable  to  the  disturbing  influences  of  the 
menstrual  molimen,  we  may  liave  recourse  to  this  operation  as  a  dernier  res- 
sort. 

The  operation  may  be  performed  through  the  abdominal  or  vaginal 
wall  and  the  following  rules  are  given:  ^  (1.)  Remove  both  ovaries 
entire  in  every  case.  (2.)  As  a  rule,  operate  by  the  abdominal  sec- 
tion, because,  if  the  ovaries  are  bound  down  by  adhesions  it  is  pos- 
sible to  remove  them  entire,  whereas  by  the  vaginal  incision  it  iS 
impossi'ule.  (o.)  If  there  has  been  no  pelvic  inflammation,  no  cel- 
lulitis, no  ha^matocele,  no  adhesion  of  the  ovaries  to  the  neighboring 
parts,  then  the  operation  may  be  made  by  the  vagina,  but  not  other- 
wise. 

1.  Removal  by  abdominal  section  requires  the  same  incision 
and  proeeilure  ;is  in  the  removal  of  ovarian  growths. 

2.  Extirpation  of  the  ovary  through  the  vagina  is  performed  as 
follows:  1  The  patient,  having  been  fully  etherized,  must  be  placed 
upon  the  table  in  the  prone  posture;  ^  now  retract  the  perineum  by 
a  speculum;  grasp  the  cervix  uteri  with  a  volsella  and  draAv  the 
uterus  firmly  downwards;  make  an  incision  through  the  walls  of  the 
vaginal  cul-de-sac  in  the  line  of  the  fornix  vaginae;  control  the 
slight  haemorrhage  by  cold  sponges;  grasp  the  peritoneum,  nick  and 
open  it  to  the  length  of  the  original  incision;  pass  the  forefinger  into 
the  cul-de-sac,  and  examine  the  ligaments  and  Fallopian  tubes,  and 
determine  the  position  of  the  ovaries;  draw  one  as  closely  as  possi- 
ble to  the  incision,  grasp  it  with  forceps,  draw  it  tlirough  the  opening 
into  the  vagina,  pass  a  stout  ligature  around  the  pedicle,  apply  the 
chain  of  the  ecraseur  and  slowly  sever  the  attachments  ;  pursue  the 
same  method  with  the  other  ovary;  cleanse  the  vagina,  and  secure 
quiet  and  rest. 

1  K.  Battey.  2  j.  m.  Sims. 


THE  OVARIES.  561 


II.     CYSTIC    TUMORS. 


These  tumors  assume  many  forms;  tliey  may  he  large  and  small, 
simple  and  compound,  and  may  have  watery,  colloid,  fatty,  sanguino- 
lent,  or  nd.xed  contents.^ 

The  more  important  are  the  colloid  cysts, 2  characterized  by  tliick,  viscid,  fre- 
quently yellow  or  limwiiisli  f^elalinous  contents;  they  are  al\va\s  multiple  at  the 
outset,  niultilocular  cysts,  and  are  usually  present  in  large  nuniliers;  in  cases  of 
long  standiiiir  it  often  happens  that  one  or  several  cysts  are  much  larger  than  the 
rest,  and  tinally  there  may  be  but  one  present,  unilocular  cyst,  which  is  formed 
by  the  union  of  many  smaller  ones;  as  the  manner  of  growth  of  these  cysts  has 
a  great  resemblance  to  that  of  the  normal  Graafian  follicles,  they  have  been 
called  adenomata.  By  a  conversion  of  the  colloid  contents  into  a  more  fluid 
substance,  and  by  a  constant  secretion  of  liquid  from  tlie  walls,  the  epithelial 
cells  of  which  often  perish,  what  is  known  as  niultilocular  ovarian  drops}- origin- 
ates. Polypoiil  growl  lis  are  often  seen  on  the  inner  surface  of  these  cysts,  and 
extend  into  their  interior;  the  cvsts  may  miiiergo  secondary  changes  by  the  ad- 
mixture of  blood  with  their  contents,  which  gives  them  a  brown  color.  Sup- 
puration may  take  place  from  the  wall,  and  the  contents  may  become  iciiorous, 
usually  in  consequence  of  operative  interference.  In  the  case  of  large  cj-sts, 
adhesions  to  the  abdominal  walls,  intestine,  etc..  are  almost  constant.  Besides 
the  pure  cystomata  there  are  a  large  number  of  cystic  tumors  of  different  na- 
tures, for  most  ovarian  tumors  are  prone  to  become  cystic;  thus  there  is  a  cysto- 
fibroma,  cystocarcinoma. 

Cysts  of  the  ovary  are  diagnosed  from  solid  tumors  by  fluctuation; 
from  ascites  by  the  limited  extent  of  the  wave-impulse ;3  from  tu- 
mors of  the  uterus  by  their  location,  exploration  of  the  cavity  of  the 
uterus  by  sounds,  examination  by  the  hand  in  the  rectum,*  tapping  or 
testing  the  fluid.     The  treatment  is  tapping  or  extirpation. 

1.  Tapping  the  ovary  should  be  preferred  when  the  cyst  is  single, 
and  no  si'condary  growths  can  be  detected  in  the  cyst  wall;  if  the 
0])eration  be  performed  with  precaution,  the  risk  is  extremely  small, 
the  patient  loses  nothing,  and  a  cure  may  follow.^     The  operation 


Fig.  57(5.5       ^^^ 

may  be  performed  through  the  abdominal  wall,  the  vagina,  or  rec- 
tum. When  the  abdominal  wall  is  selected,  the  only  danger  is 
wound  of  a  blood  vessel,  and  the  entrance  of  air  into  the  cavity  of 
the  cyst;  the  former  accident  is  so  rare  as  to  require  no  considera- 

1  E.  Rindfleisch.  2  j.  Qrth.  3  T.  S.  Wells.  -i  Simon. 

5  Geo.  Tiemann  &  Co. 
30 


562  OPERATIVE  SURGERY. 

tion;^  the  latter  may  be  prevented  by  antiseptic  measures,  or  the  use 
of  a  proper  trocar  and  canula  (Fig.  576).'^ 

The  trocar  is  withdrawn  after  the  puncture;  the  canula  being  within  the  cyst 
the  fluid  escapes  through  the  rubber  tube  attached  to  tiie  button  on  the  side; 
the  extreme  end  of  the  tube  is  immersed  in  a  tub  of  water. 

The  preparation  of  the  patient  and  the  details  of  the  operation 
are  the  same  as  in  paracentesis  abdominis.  It  is  important  to  ob- 
serve the  following  rules:  ^  — 

(1)  Never  tap  while  the  patient  sits,  but  always  as  she  lies  upon  the  side  or 
back;  (2)  cut  the  skin  with  a  lancet,  and  employ  a  trocar  and  canula  with  tube 
immersed  in  water  to  prevent  tiie  entrance  of  air;  (3)  if  the  fluid  withdrawn  is 
viscid,  always  wash  out  tlie  cavity  of  the  sac  with  warm  carbolized  water;  (4) 
should  there  be  oozing  of  blood,  pass  a  harelip  pin  deeply  through  tlie  lips  of 
the  wound  and  affix  the  figure-eight  ligature;  (5)  keep  the  patient  recumbent 
and  very  quiet  for  two  or  three  days. 

Tapping  by  the  vagina  is  more  liable  to  be  followed  by  the  en- 
trance of  air  into  the  cyst,  suppuration,  and  fever.'*  It  is  most  use- 
ful when  the  cyst  is  found  fixed  in  the  pelvis,  as  it  may  be  followed 
by  drainage  and  antiseptic  injections.  Place  the  patient  in  the  lith- 
otomy position,  the  bladder  and  rectum  having  been  evacuated;  in- 
troduce the  index  and  second  fingers  into  the  vagina  until  they  rest 
upon  the  most  prominent  part  of  the  tumor;  carry  a  canula  ten 
inches  long,  with  the  trocar  slightly  withdrawn,  along  the  finger,  and 
plunge  the  trocar  into  the  cyst,  after  the  fluid  has  escaped,  secure 
perfect  quiet  and  guard  against  inflammation.^ 

Electrolysis  has  been  strongly  recommended  for  its  power  to  promote  ab- 
sorption as  a  reliable  method  of  treating  ovarian  tumors,  but,  Judging  from  sta- 
tistics and  general  considerations, ^  it  would  seem  that  it  can  in  nowise  supplant 
ovariotoni}-. 

2.  Ovariotomy  ^  is  an  extreme  measure,  and  though  very  successful 
as  regards  mortality,  should  not  be  advised  without  due  deliberation. 
In  general,  it  should  not  be  recommended  while  the  patient  is  mod- 
erately comfortable;  while  she  can  walk  a  mile,  or  for  half  an  hour, 
without  much  inconvenience;  while  she  can  get  up  and  down  stairs; 
while  there  is  no  great  pressure  upon  any  of  the  organs  of  the  abdo- 
men or  pelvis ;  when  she  can  breathe  pretty  well  the  heart  is  not 
affected.  The  proper  time  for  surgical  interference  is  when  the 
patient  is  so  far  inconvenienced  by  the  tumor  and  so  much  distressed 
from  its  size,  that  she  cannot  move  about  without  great  discomfort, 
her  general  health  is  suffering,  she  is  losing  her  rest,  becoming  thin, 
and  some  serious  damage  is  being  done  by  the  pressure  of  the  cyst; 
but  the  operation  must  not  be  put  off  until  there  is  no  reasonable  hope 

1  T.  S.  Wells.  2  T.  A.  Emmet.  3  T.  G.  Thomas. 

*  T.  S.  Wells ;  T.  G.  Thomas.      5  P.  F.  Munde. 


THE   OVARIES. 


563 


of  success.  Almost  positive  f.-ontra-imlicafion  to  an  operation  would 
be  tlie  fact  that  the  patient  has  some  other  disease  which,  if  left  to 
its  natural  course,  would  certainly  prove  fatal.' 

The  operation  havinjj;  been  determined  upon,  every  precaution 
must  be  taken  to  render  it  successful.  The  patient  must  be  lodged 
in  the  best  house,  in  the  best  sanitary  condition,  and  in  the  best  room 
that  can  be  secured.'  As  antiseptic  precautions  have  added  ;j;reatlv 
to  the  safety  of  the  operation  the  room  should  be  thoroujjhlv  disin- 
fected, either  by  sulphur  "■^  or  carbolic  acid;^  the  attendants,  assist- 
ants, and  operator  should  be  entirely  free  from  every  form  of  con- 
tagious and  putrescible  matter,  both  as  to  their  persons  and  clothing; 
the  air  of  the  room  should  be  pure  and  may  be  disinfected  with  the 
finest  carbolic;  fog  before  and  during  tlie  operation,  created  bv  a 
proper  steam  atomizer;  all  the  sponges,  instruments,  and  dressings 
should  he  carbolized.  Proceed  as  follows:  '  Place  the  patient  on  a 
table,  wrap  the  feet  and  legs  with  a  sheet,  fasten  a  strap  over  her 
knees,  and  tie  the  hands  to  the  legs  of  the  table  with  an  ordinary 
bandage  looped  over  the  sleeve;  give  the  anaesthetic;  the  patient  and 
becUling  are  protected  by  a  sheet  of  waterproof  cloth,  with  a  hole 
in  the  centre,  around  which,  on  the  inside,  adhesive  plaster  is  spread 
to  the  extent  of  an  inch  to  an  inch  and  a  half;  when  this  sheet  is 
thrown  over  the  patient,  the  plaster  adheres  to  the  skin  of  the  ab- 
domen; the  body,  clothing,  and  face  is  protected  from  the  spray,  if 
that  is  used;  make"  the  incision  with  an  ordinary  scalj)el,  along  the 
linea  alba,  below  the  umbilicus,  and  expose  the  peritoneum;  sup- 


FiG.  577.* 

press  all  bleeding  by  seizing  the  vessels  with  artery  forceps;  divide 
the  peritoneum  by  catching  it  up  with  forceps,  or  a  Jittle  hook,  avoid- 
ing the  cyst  which  may  lie  close  against  the  abdominal  wall;  nick 
the  peritoneum  with  the  scalpel  laid  flat,  pass  a  broad  director  into 
the  opening,  and  with  a  blunt-pointed  knife  divide  this  membrane 
1  T.  S.  Wells.  2  Ilegar.  »  Hegar;  Keith.  ■•  S.  Fitch. 


564 


OPERATIVE  SURGERY. 


three  or  four  inches,  as  may  be  necessary,  and  expose  the  cyst;  now 
empty  the  cyst  with  a  trocar  (Figs.  5  7  7,  5  78),  draw  the  tumor  out 
of  the  abdomen  until  the  pedicle  comes  into 
view,  when  the  clamp  is  applied  (Fig.  579).^ 


Fig.  578.2 


Fig.  579. 


The  dome-trocar  3  (Fig.  576)  is  represented  in  1,  2,  3;  the  distal  orifice  of  the 
inner  canula,  /,  is  closed  over  hy  a  rounded  or  dome-shaped  roof,  vi,  so  that,  when 
it  is  projected  beyond  the  cutting-point  of  the  outer  canula,  the  two  tubes,  n,  m, 
fit  closely  together,  and  the  end  of  the  combined  instrument  feels  perfectly 
smooth  like  the  end  of  a  sound  or  catheter,  and  may  be  freel}-  moved  within  the 
cavity  penetrated,  as  the  ovarian  cj'st,  the  abdomen,  the  thorax,  the  bladder,  or 
even  the  pericardium,  without  danger  of  wounding  any  viscus  or  organ,  punc- 
turing any  vessel,  or  even  scratching  or  abrading  the  lining  of  the  cavity,  or  of 
any  parts  contained  therein;  the  base  of  this  dome  being  of  the  same  external 
circumference  as  the  inner  tube,  of  which  it  is  the  continuation,  and  fitting  the 
outer  tube  accurately,  when  the  point  of  the  instrument  enters  a  cavit}-  there 
can  be  no  escape  of  fluid,  till  the  dome  is  advanced,  occluding  the  cutting-point 
i)f  the  outer  tube;  then  there  is  disclosed  a  fenestra  or  oval  apertiu-e  on  the 
under  side  of  the  inner  tube,  n,  cut  out  of  the  lower  wall  and  one  third  of  each 
side  wall,  of  the  full  size  of  the  bore  of  the  tube,  and  by  which  the  fluid  may 
be  freely  evacuated ;  the  thumb-rest,  c,  attached  to  the  inner  canula  may  be 
pushed  forward  in  the  slot  d,  and  turned  into  the  branch-slot  e,  advancing  the 
dome  and  bringing  the  fenestra  to  the  under  side.  The  tubular  handle  has  the 
larger  end  fastened  upon  the  outer  canula  by  the  screw  ff.  In  attaching  the 
larger  end  of  the  handle  to  the  outer  canula,  push  the  process,  projecting  from 
this  end,  into  the  slot  in  the  proximal  end  of  the  canula,  and  then  turn  the  loose 
ferrule  till  the  mortise  in  its  side  corresponds  to  the  screw  g. 

The  mode  of  dealing  with  adhesions  is  as  follows:*  If  the  cyst  is  found  closely 

1  T.  G.  Thomas.  2  q.  Tiemann  &  Co.        S  g.  Filch.        *  T.  S.  Wells. 


THE  OVARIES.  565 

adherent  to  the  walls,  the  safest  filaii  is  to  empty  the  principal  cyst  before  making 
any  attempt  to  separate  the  adhesions,  for  the  peritoneum  Ijeing  nndisturbed, 
the  fluid  escapiiif^  from  the  cyst  cannot  pass  into  the  peritoneal  cavity;  whea 
the  cyst  is  empty  it  is  often  extremely  easy  to  draw  it  out  by  passing  one  hand 
into  the  interior,  then  gras|)iny  the  back  of  the  cyst  and  inverting  it,  drawing 
out  the  back  part  first.  If  this  cannot  be  done,  proceed  to  enlarge  the  wound 
and  find  exactly  where  the  limit  is  between  the  cyst  and  abdominal  wall,  and 
proceeding  to  that  point,  with  one  hand  draw  the  cyst  outwards,  while  with  the 
other  separate  the  adhesions;  occasionally  firm  bands  must  be  separated  with 
the  knife  or  scissors. 

The  peritoneal  cavity  is  now  thoroughly  cleaned  with  sponges,  and 
the  sutures  applied;  these  sutures  are  silk,  each  end  being  threaded 
to  a  needle,  and  kept  wrnpped  in  carliolized  gauze;  with  a  needle- 
holder,  each  needle  is  passed  from  within  outward,  a  sponge  being 
placed  over  the  bowels  to  catch  any  drop  of  blood,  by  taking  up  one 
side  of  the  wound  in  the  thumb  and  finger,  and  passing  the  needle 
from  within  outward,  through  the  whole  thickness,  and  then  the 
other  side  is  raised  and  the  other  needle  is  passed  in  the  same  man- 
ner; the  intestines  cannot  be  penetrated  when  this  j)recaution  is 
taken;  pass  five,  six,  or  eight,  according  to  the  length  of  the  incision; 
now  remove  the  sponge,  and  while  an  assistant  supports  the  sides  of 
tlie  abdomen,  tic  the  sutures  with  the  surgeon's  knot;  dry  dressings 
are  applied  and  strips  of  plaster  to  retain  them  in  place,  with  a 
flannel  bandage.* 

As  a  means  of  controlling  high  temperature,  after  the  operation,  affusion  has 
been  successfully  practiced.-  The  bed  3  on  which  the  patient  lies  consists  of  a 
strong,  elastic,  cotton  netting,  manufactured  for  the  purpose,  through  which 
water  readily  passes  to  the  bottom  below,  which  is  of  rubber  cloth,  so  adjusted 
as  to  convey  it  to  a  vessel  at  the  foot.  Upon  this  cot  a  folded  blanket  is  laid  so 
as  to  protect  the  patient's  body  from  cutting  by  the  cords  of  the  netting,  and  at 
one  end  is  placed  a  pillow  covered  with  India-rubber  cloth,  and  a  folded  sheet 
is  laid  across  the  middle  of  the  cot  about  two  thirds  of  its  extent.  Upon  this 
the  patient  is  now  laid,  her  clothing  is  lifted  up  to  the  arm-pits  and  the  body 
enveloped  by  the  folded  sheet,  which  extends  from  the  axillic  to  a  little  below 
the  trochanters.  The  legs  are  covered  by  flannel  drawers  and  the  feet  by  warm 
woolen  stockings,  and  against  the  soles  of  the  latter  bottles  of  warm  water  are 
placed.  Two  blankets  are  then  placed  over  her,  and  the  application  of  water  is 
made.  Turning  the  blankets  down  below  the  pelvis,  the  physician  now  takes 
a  large  pitcher  of  water  at  from  75^  to  80'  and  pours  it  gently  over  the  sheet. 
This  it  saturates,  and  then,  percolating  the  network,  it  is  caught  by  the  India- 
rubber  apron  beneath,  and,  running  down  the  gutter  formed  by  this,  is  received 
in  a  tub  placed  at  its  extremity  for  that  purpose.  Water  at  higher  or  lower  de- 
grees of  heat  than  this  may  be  used.  As  a  rule,  it  is  better  to  begin  with  a  high 
temperature,  8.j'  or  even  9(P,  and  gradually  diminish  it.  The  patient  now  lies 
in  a  thoroughly  soaked  sheet  with  warm  bottles  to  her  feet,  and  is  covered  up 
carefully  with  dry  blankets;  neither  the  portion  of  the  thorax  above  the  shoul- 
ders nor  tlie  inferior  extremities  are  wet  at  all;  the  water  is  applied  only  to  the 
trunk. 

1  T.  .S.  Wells.  -  T.  ei.  Thomas.  3  (j    \v.  Kibbee. 


566  OPERATIVE  SURGERY. 


CHAPTER  LIV. 

THE   UTEKUS. 

The  uterus  is  a  hollow  organ,  having  an  average  length  of  three 
inches,  a  breadth  at  its  widest  part  of  two  inches,  and  a  thickness  of 
one  inch  ;  its  position  corresponds  with  the  axis  of  the  inlet  of  the 
pelvis,  its  upper  end  being  turned  upwards  and  forwards;  it  is  cov- 
ered behind,  above,  and  in  front,  except  where  it  is  connected  with 
the  base  of  the  bladder,  by  the  peritoneum ;  from  its  lateral  surfaces 
the  peritoneum  is  reflected,  forming  the  broad  ligaments;  its  neck  is 
narrow  and  round,  from  six  to  eight  lines  in  length,  and  projects  into 
the  upper  end  of  the  tube  of  the  vagina;  at  the  lower  extremity  is 
the  OS  uteri,  by  which  its  cavity  communicates  with  the  vagina.^ 

1.  Exploration  of  the  cavity  of  the  uterus  is  made  with  the 
uterine  sound,  by  which  it  is  possible  to  ascertain  the  capacity  of 
the  uterus;  the  existence  of  growths  within  it;  deviations  of  the 
course  of  its  canal;  differentiation  of  displacements  from  uterine 
tumors;  the  existence  of  endometritis;  the  mobility  of  the  uterus. "-^ 

The  uterine  sounds  a,  b,  c  (Fig_^  580),  usually  of  metal,  may  be  curved  to  suit 
any  canal.  For  measurinj^  the 
cavity,  buttons  niaj'  be  applied 
to  the  shaft,  c;3  the  end  of  the 
probe  being  in  contact  with  the 
finidus,  the  section  having  a 
button  on  the  end  is  projected 
until  it  conies  in  contact  with 

the  cervix,   and   the    distance  ^^^-  ^^^•'* 

from  the  button  to  the  end  of  the  sound  is  the  length  of  the  cavity.  A  slender 
rod  of  whalebone,  ending  in  a  knob, 2  is  useful  for  measuring  a  uterus  enlarged 
bv  a  submucous  fibroid,  and  for  separate  measurement  of  the  neck  and  body. 

Place  the  patient  on  the  back,  and  ascertain  by  the  touch  the  po- 
sition of  the  uterus;  then  introduce  the  speculum,  and  pass  the  sound 
curved  according  to  the  direction  of  the  uterine  canal;  if  it  does  not 
pass,  change  its  curve  to  meet  deviations,  for  success  is  attained  only 
by  properly  curving  the  probe.^ 

The  tent  is  employed  to  dilate,  the  cervical  canal  to  allow  of  the 
examination  of  the  cavity  by  the  touch  or  sight ;  it  may  be  made  of 
sponge  or  of  sea-tangle,  laminaria  digitata.  The  folloM'ing  rules  '^  in 
regard  to  their  use  should  be  observed  :  — 

(1)  Xo  force  should  be  used  in  their  introduction:  if  the  first  tent  does  not 
pass  easily,  withdraw  it,  and  either  bend  it  to  a  more  suitable  shape,  or  select 

1  Quaiu's  Auatonn-.      "-  T.  G.  Thomas.      ^   \.  j_  Skene.     ■*  Tiemanu  &  Co. 


G2^?S> 


THE    UTERUS. 


567 


=^ 


a  smaller  tent.  (2)  Never  introduce  a  tent  at  your  office  and  allow  the  patient 
to  £jo  home  with  it  in  utero.  (3)  The  previous  existence  of  ciironic  pelvic  peri- 
tonitis cotitra-indicjites  the  tent.  (4)  A  tent  should  never  be  allowed  to  remain 
in  the  uterus  more  tlian  twenty-four  hours.  (5)  After  removal  of  a  tent,  wash 
out  the  vagina  with  antiseptic  fluid;  and,  if  there  is  pain  or  chilliness,  give 
opiates.  After  the  removal  of  a  tent,  the  patient  should  be  kept  in  bed  for 
twenty-four  hours. 

2.  Cervical  constriction,  causing  (lysint-norrlicea,  is  best  treated 
by  inakiiiii  a  superficial  incision  through  the  submucous  layers  of  the 
parenchyma  from  the  os  iuteruum  through  the  whole  course  of  the 
canal.  Intro- 
duce the  hys- 
terotome  (Fig. 
681)1     up     to  Fig.  581.2 

the    OS    inter- 
num, turn  the  screw  at  the  end  of  the  handle,  by  which  the  two  blades 
are   thrown   out,   and  withdraw   the    instrument;    place    within   the 
canal  a  roll  of  cotton  saturated  with  a  weak  solution  of  persulphate 
of  iron,  and  allow  it   to  remain  forty-eight  hours;    at  the  eml  of  a 

fortnight  replace  it   by  a  stem  of 
glass  or  vulcanite. 

The  stem  should  measure  two  inches, 
and  rest  by  its  globular  base  in  a  cup 
fixed  between  the  bars  of  a  retroversive 
pessary  (Fig.  .582);  this  apparatus  is  best 
I'ljiisii'd  with  the  aid  of  the  speculum. 3 
3.  Retroversion  of  the  utertis, 
occuring  from  succussion,  is  at- 
tended with  severe  symptoms;  the 
patient  falls  to  the  ground  an<l  is 
uiu\ble  to  rise,  experiences  the  se- 
verest pelvic  pain,  suffers  from  suppression  of  urine  ami  fa?ces,  aiul 
is  often  in  such  agony  that  the  face  is  bathed  with  perspiration,  and 
the  pulse  becomes  weak  and  fluttering.  The  finger  in  the  vai:ina  dis- 
covers the  cervix  near  the  symphysis  pubis,  and  a  hard,  round  mass 
resting  upon  the  rectum;  if  there  is  doubt  in  the  diairnosis,  use  the 
uterine  probe  which  will  determine  the  direction  of  the  axis.  Place 
the  patient  on  the  left  side,  in  a  semi-prone  position,  as  for  a  specu- 
lum examination  ;  standing  at  the  patient's  back,  and  facing  her 
head,  introduce  the  index  and  middle  fingers  of  the  right  hand,  well 
lubricated,  the  palmar  surfaces  directed  to  the  rectmn;  lift  the 
uterus  upon  the  inner  surfaces  of  the  fingers  until  it  becomes  erect, 
then  their  dorsal  surfaces,  or  backs  of  the  nails,  are  made  to  push 
the  organ  into  position. 

1  T.  G.  Thomas.  2  0.  While.  8  J.  .M.  Sims. 


568  0PERAT1\^  SURGERY. 

If  the  uterus  is  irreducible,  and  requires  more  powerful  means, i  evacuate  the 
bladder  and  reetiun,  loosen  the  clothing,  have  the  patient  kneel  upon  a  hard 

surface,  with  the  sternum  as  closely 
as  possible  in  contact  with  tiie  same 
plane;  introduce  the  two  fingers  into 
the  vagina,  place  them  against  the 
fundus,  and  direct  the  patient  to  till 
"""■-^    the  chest  with  air  and  expel  it  com- 
""•"^     )    pletely;' at  this  moment,  elevate  the 
"'^-.y    fundus,  and  restore  it  to  its  place. 
^'^- ^^•^-  If  this  effort  fail,  elevate  the  hips 

still  more,  and  repeat  the  attempt  with  the  fingers  in  the  rectum,  instead  of  the 
vagina.  If  these  methods  fail,  instruments  should  not  be  employed.  In  cases 
requiring  less  force,  a  repositor  may  be  used  (Fig.  583)  ;2  the  stem  is  introduced 
to  the  fundus,  and  is  then  moved  in  the  proper  direction,  by  the  slide,  a,  carry- 
ing the  organ  into  position. 

3.  Uterine  polypus '  is  a  tumor  covered  by  the  mucous  mem- 
brane of  the  uterus  and  attached  to  that  organ  by  a  pedicle.  The 
symptoms  are  leucorrhoea,  pain  in  the  back  and  loins,  menorrhagia, 
metrorrhagia,  and  hydrorrha'a;  if  the  tumor  is  attached  to  the  cer- 
vix it  may  be  felt  hanging  from  the  canal  or  in  the  os  uteri;  if  it 
is  in  the  cavity,  and  small,  its  presence  ■will  not  be  detected  by  the 
sound,  but  there  is  often  a  copious  flow  of  blood  following  the  with- 
drawal of  the  instrument;  if  large,  the  uterus  will  be  displaced  and 
enlarged,  and  the  cervix  somewhat  dilated.  But  no  examination  can 
be  considered  complete  until  the  cervix  has  bt-en  fully  dilated  by 
tents  and  exploration  has  been  made  by  touch.  If  a  polypus  exist  in 
utero  and  the  cervical  canal  be  firmly  closed,  avoid  immediate  at- 
tempts at  removal,  unless  the  symptoms  are  grave;  employ  jialliative 
measures  until  dilatation  of  the  cervix,  and,  perhaps,  expulsion  into 
the  vagina  are  effected;  to  facilitate  expulsion,  dilate  by  tents,  or 
incise  the  walls  of  the  cervix  laterally,  and  use  ergot  steadily,  either 
internally  or  hypodermically ;  if  the  os  internum  be  fully  dilated, 
and  the  tumor  be  in  utero,  seize  it  with  a  volsellum  at  its  lowest  ex- 
tremity, and  make  a  cautious,  but  rapid,  attempt  at  its  removal  by 
torsion  and  traction,  but  lengthy  manipulations  in  utero  are  always 
very  hazardous;  if  it  cannot  be  removed  in  this  way,  slide  up  along 
the  wall  of  the  tumor  upon  which  steady  traction  is  made,  an  ^cra- 
seur  or  a  pair  of  sharply-curved  scissors,  and  sever  the  stem. 

5.  Fibrous  tumors  of  the  uterus  ^  are  submucous,  interstitial,  or 
sub-peritoneal.  The  more  frequent  symptoms,  especially  of  the  sub- 
mucous variety,  arc  menorrhagia,  irritability  of  rectum  and  bladder, 
pain  throuuh  the  pelvis,  uterine  tenesmus,  profuse  leucorrhoea,  dys- 
nienorrhcea,  pressure  on  the  crural  veins  and  vessels,  watery  dis- 
charge from  uterus.  Exploration  should  be  conducted  as  follows: 
1  T.  G.  Thomas.  2  x.  A.  Emmet. 


THE   UTERUS.  569 

Place  tlie  patient  on  the  back,  witli  tlic  thi'^lis  flexed;  all  constriction 
of  the  waist  should  be  removed  and  the  bladder  and  rectum  emptied; 
depressing  the  uterus  by  the  right  hand  placed  over  the  hyi)Ogastrium, 
sweep  the  index  finger  of  the  other  as  high  up  as  possible  over  the 
posterior  wall,  first  by  vaginal  and  then  by  rectal  t(tuch;  lift  the 
uterus  with  the  fingers  within,  and  force  the  tips  of  the  fingers  on 
the  abdomen  behind  the  fundus,  and  downwards  over  the  posterior 
wall  so  as  to  approach  the  fingers  in  the  pelvis,  and  thus  explore  this 
region;  next,  draw  the  cervix  forwards  with  the  finger  in  the  vagina 
and  pass  the  fingers  external  over  the  anterior  wall,  and  explore; 
to  examine  the  cavity,  dilati'  the  cervix  fully  by  tents  of  sponge  or 
sea-tangle,  and,  on  their  removal,  depress  the  uterus  and  introduce 
the  finger.  The  treatment  of  the  vast  majority  of  the  submucous  and 
and  interstitial  vaiiety  should  be  palliative;  if  the  uterus  is  displaced, 
rectify  its  position  and  support  it  with  a  pessary;  if  the  haemorrhage 
is  excessive,  secure  rest,  give  haemostatics,  or  apply  the  tampon  of 
cotton  with  solution  of  alum;  or,  if  the  bleeding  continue,  make  deep 
incisions  of  the  uterine  canal  on  either  side.  Methods  of  treatment 
applicable  to  all  uterine  fibroids  are  absorption,  excision,  avulsion, 
enucleation,  gastrotomy.  Absorption  has  been  effected  by  the  per- 
sistent use  of  iodine  and  ergot;  the  former  in  large  doses  of  the 
iodide  of  potassium,  and  the  latter  by  hypodermic  injection  of  the 
atpieous  extract  of  erc::ot  three  parts,  to  glycerine  seven  and  a  half 
parts,  and  the  same  of  water.  Excision,  avulsion,  and  eiuicleation 
require  dilatation  of  the  cervical  canal,  and  projection  into  the 
uterine  cavity.  If  a  small  tumor  project  it  may  be  removed  by  the 
knife,  scissors,  or  other  cutting  instrument;  but  if  the  ecraseur  can 
be  used,  it  should  be  preferred  ;  should  the  tumor  be  very  large  and 
fill  the  vagina,  it  may  be  drawn  down  by  obstetric  forceps;  or  it  may 
be  cut  away,  piece  by  piece,  by  knife  or  scissors,  and  removed,  until 
its  base  is  reached;  or  the  galvano-cautery  or  ecraseur  may  be  used, 
portion  after  portion  being  removed.  Avulsion  is  practiced  with 
vulsellum  forceps,  firm  traction  with  slight  rotatory  movement  being 
made;  if  the  tumor  do  not  yield,  introduce  one  hand  into  the  vagina 
and  two  fingers  into  the  uterus,  and  rupture  the  attachments  of  the 
growth.  Enucleation  is  performed  when  the  tumor  is  so  much  im- 
bedded that  other  methods  are  unavailing ;  the  cervical  canal  being 
previously  fully  dilated,  plaee  the  patient  on  her  back,  upon  a  strong 
table,  and,  while  an  assistant  firmly  depresses  the  uterus,  by  means 
of  a  pair  of  scissors,  guided  by  two  fingers,  cut  into  the  capsule  and 
into  this  opening  pass  the  index  finger,  and  fix  the  tumor ;  by  means 
of  scissors  or  a  probe-pointed  bistoury,  make  a  crucial  incision 
throngh  the  capsule  as  freely  as  circumstances  will  admit ;  now  pass 
one  hand  cautiously  into  the  vagina,  and  forcing   the  uterus  towards 


570  OPERATIVE  SURGERY. 

the  vulva,  with  the  other  proceed  to  peel  back  the  capsule  and  enu- 
cleate the  mass.  Or,  a  long  crucial  incision  may  be  made  over  the 
presenting  part  of  the  tumor,  the  lips  of  the  capsule  separated  by 
the  finger,  and  the  patient  put  upon  the  systematic  use  of  ergot,  in 
the  hope  that  the  body  of  the  tumor  may  be  expelled  by  uterine 
efforts.  Gastrotomy,  undertaken  for  the  removal  of  sub-peritoneal 
tumors,  is  justifiable  when  the  general  decadence  of  the  patient's 
strength  makes  it  certain  that  a  fatal  issue  must  soon  ensue.  The 
operation  is  the  same  as  ovariotomy,  except  that  the  pedicle  of  the 
tumor  is  the  uterine  neck  or  upper  portion  of  the  vagina;  this  part 
is  tied  with  a  double  ligature  in  two  i)ortions. 

6.  Caesarean  section,  laparo-hysterotomy,  is  undertaken  to  re- 
move the  child  from  the  uterus  in  cases  of  extreme  contraction  of 
the  pelvis,  or  of  the  sudden  death  of  the  mother.  Operate  antisep- 
tically,  if  possible.  First  empty  the  bladder;  make  an  incision  in 
the  median  line  from  the  navel,  nearly  to  the  pubes,  and  expose  the 
uterus ;  while  it  is  supported,  laterally,  incise  the  walls  between  the 
fundus  and  cervix  ;  rupture  the  membranes,  and  remove  the  child 
by  the  feet ;  pass  the  hand  between  the  anterior  wall  and  membranes, 
and  remove  the  placenta;  prevent  haemorrhage  from  the  uterus  by 
pressure  or  cold,  cleanse  the  cavity  and  vagina  of  all  coagula  with 
carbolized  solutions  ;  close  the  wound  of  the  uterus  by  carbolized 
catgut  sutures,  cut  short,  and  the  abdominal  wound  with  wire  sutures. 

As  a  substitute  for  this  operation,  dilatation  of  the  cervix,  section  of  the  ab- 
dominal wall,  and  of  ilie  vagina,  laparo-elytrotomy,  has  been  recommended,^ 
as  involving  less  danger  to  the  mother,  because  avoiding  section  of  the  perito- 
neum. In  actual  practice  it  is  said  to  have  given  much  better  results  than  Ctesa- 
rean  section.-  The  operator  should  be  provided  with  a  pocUet-case  of  instruments, 
ether,  dilators, <*  and  thermo-cautery,^  or,  in  place  of  it,  ordinary  cautery-irons. 
The  patient  having  been  etherized,  should  be  placed  ii])on  a  firm  table,  and  the 
OS  fully  dilated  by  dilators. ^  The  abdominal  wound  should  be  made  thus:  with 
a  bistoury  cut  through  the  abdominal  nmscles,  the  incision  being  carried  frona 
the  spine  of  the  pubis  to  the  anterior  superior  spinous  process  of  the  ilium; 
separate  the  lips  of  the  wound,  and  by  two  fingers  lift  the  peritoneum,  so  that 
the  vagino-uterine  junction  is  reached;  lift  the  vagina  by  a  steel  sound  passed 
within  it,  and  cut,  and  enlarge  the  opening  by  the  fingers;  lift  the  cervix  into 
the  right  iliac  fossa  by  the  blinit  hook,  while  the  fundus  is  depressed  in  an  op- 
posite direction;  then  pass  the  right  hand  into  the  iliac  fossa  and  introduce  two 
fingers  into  the  uterus,  while  the  left  hand,  placed  on  the  outer  surface  of  the 
uterus,  depresses  the  pelvic  extremity  of  the  foetal  ovoid;  deliver  the  child  by 
version,  if  the  head  or  arm  present;  by  extraction,  if  the  breech  do  so.  The  pla- 
centa having  been  delivered,  and  the  uterus  caused  to  contract  firmly,  the  iliac 
fossa  shotdd  be  cleansed  by  a  sti-eam  of  warm  water,  introduced  through  the 
abdominal  wound,  and  escaping  through  the  vagina;  and  if  hemorrhage  exist, 
ligatures  should  be  applied,  if  possible  through  the  abdominal  wound,  to  the 
bleeding  vessels.     Should  this  prove  impossible,  the  vagina  should  be  distended 

1  T.  G.  Thomas;  A.  J.  Skene;  H.  .T.  Garrigues.  2  H.  J.  Garrigues. 

3  R.  Barnes'.  ■*  raquolin's. 


Tin:    VAGINA.  571 

by  a  lai-ge  metallic  speculum,  and  the  lips  of  the  abdominal  wound  being  widely- 
separated,  the  bleeding  points  touched  by  the  actual  cautery  ca'ried  down  from 
above.  Should  this  fail,  the  uterus  should  bi-  made  to  contract  lirmly  by  ergot, 
and  both  vagina  and  iliac  fossa  be  thoroughly  tamponed  with  cotton  soaked  in 
water  and  squeezed,  but  free  from  any  styptic.  'I'heii  a  broad  band  of  adhesive 
plaster  and  a  compress  should  be  applied  over  the  lower  portion  of  the  abdo- 
men. Should  no  undue  ha'morrhage  occur,  the  abdominal  wound  should  be 
closed  by  interrupted  silver  sutures;  the  vagina  should  be  syringed  out  every 
live  hours  with  warm  carbolized  water,  the  nozzle  of  the  syringe  being  carried 
through  the  vaginal  oi)ening,  and  the  lliiid  forced  out  through  that  in  the  ab- 
domen. The  patient  should  be  kept  perfectly  quiet,  nourished  by  milk  and 
animal  broths,  and  kept  free  from  pain  by  opium. 

7.  Cancer  of  the  uterus  is,  in  ;vt  least  half  of  the  oa.ses,  in  the 
form  of  an  epitlu'liuiua;  it  oi-iy,inates  ffoin  the  nnicoiis  lining  of  the 
cervi.K  or  from  the  vaginal  portion,  and  may  give  rise  to  very  exten- 
sive lesions  in  the  nterus,  and  may  lay  open  the  bladder,  rectum,  or 
peritoneal  cavity.'  The  symptoms"^  are  pain  through  the  pelvis, 
tenderness  upon  movement  or  coition,  menorrhagia,  ichorous  and 
fetid  leiRorrhffia,  hydrorrha'a,  dark  and  gnunous  discharge,  consti- 
tutional debility,  pallor  and  cachectic  fades,  fistula?.  The  touch 
detects,  before  ulceration,  a  hard  and  nodular  tumor,  which  is  not 
characteristic,  but  after  ulceration  the  finger  discovers  the  walls  of 
a  deep  and  ragged  ulcer,  covered  with  a  crumbling  mass  which 
readily  bleeds.  The  treatment  is  to  secure  cleanliness  by  tepid  vag- 
inal injections  of  antiseptics  and  astringents,  nourishing  diet,  ano- 
dynes, removal  by  means  of  the  electro-cautery,  if  possible;  if  ad- 
hesions render  removal  impossible,  practice  partial  removal  or  de- 
struction by  galvano-cautery,  the  scissors,  scoop,  or  curette,  or  by 
actual  cautery,  fuming  nitric  acid,  or  anhydrous  sulphate  of  zinc. 
Caustics  carefully  applied  to  the  ulcerated  surface,  often  give  great 
relief  by  arresting  the  destructive  process  and  diminishing  the  dis- 
charges. 

CHAPTER  LV. 
THE    VAGINA. 

The  vagina  is  a  membranous  and  dilatable  tulje,  extending  from 
the  vidva  to  the  uterus,  the  neck  of  which  it  embraces;  it  rests  be- 
low and  behind,  on  the  rectum,  supports  the  bladder  and  urethra  in 
front,  and  is  enclosed  between  the  levatores  ani  muscles.^ 

1.  Exploration  of  the  vagina  ^  is  made  with  the  fingers  and 
the  speculum. 

(1.)  If  the  fingers  are  used,  jilace  the  patient  on  the  back,  with  the  legs  flexed 

and  hips  near  the  edge  of  the  table;  the  index  fmger  introduced  will  determine 

1  E.  Uindlleibch.  2  T.  G.  Thomas.  «  Quain's  Aiuitomy. 


572 


OPERATIVE  SURGERY. 


Fig.  586. 


the  capacity  of  the  vagina,  the  existence  of  growths,  the  position  of  the  cervix 

uteri;  abdominal  palpation  should  always  be  combined  with  the  vaginal  touch; 

if  more  extensive  examination  is  required,  two  fingers  maj'  be  introduced,  or 

-^ even  the  whole  hand, but  in  this  case  anaesthesia 

P"* ^'  ^X     ^^  generally  nece.ssarv,  and  the  greatest  caution 

^       "  ^1*    should   be  exercised ;   to  explore  the  posterior 

Fig.  584.  region,  turn  the  patient  on  the  left  side.  (2. )  Tlie 

speculum  permits  of  visual   examination;  this 
instrument  may  be  (a)  cylindrical,  and  of  this  form  none  compare  in  elegance, 
cleanliness,   and  utility  with  the  glass  tube,   coated  with  quiclvsilver,  covered 
with  rubber,  and  thoroughly  varnished  (Fig.  584) ;  (h)  bi- 
valve (Fig.    585)    and 
quadri valve    (Fig.   586); 
(c)   single    valve  1    (Fig. 
587).     The   best  position 
for  the  patient  in  the  use 
of  the  former  specula  is 
Fig.  585.  on   the   back,  as  already 

explained;  first  depress  the  perineum  with  the  tip  of  the  conical  speculum, 
well  lubricated  with  soap,  oil,  or  vaseline,  and  then  carry  it  up  to  the  cervix; 
insert  the  valvular  instrument  closed,  and  ex- 
pand it  when  in  position;  on  removal  avoid 
catching  the  mucous  membrane  between  the 
blades.  In  the  use  of  the  single  valve,i  place 
the  patient  in  a  position  between  that  on  the 
back  and  on  the  face,  the  left  arm  drawn  be- 
hind so  as  to  let  her  rest  on  the  left  side  of  the  chest,  and  the 
right  legso  flexed  as  to  let  the  right  knee  lie  just  above  the  left; 
the  speculum  is  gently  introduced  with  the  convexity  towards 
the  perineum. 

Tliis  instrument  maj'  be  made  stationary,  and  thus  enable  the 
operator  to  both  expose  the  interior  of  the  vagina  and  apply  rem- 
edies.-    It  consists  of  the  following  parts,  arranged  for  use  thus  : 
A  brass  clamp  is  attached  to  the  edge  of  the  table  on  the  left- 
hand  side  of  the  operator;  in  this  clamp  is  fastened  a  steel  rod 
ten  inches  long;  a  brass  slide  moves  freely  up  and  down  the  rod 
and  also  revolves  upon  it,  being  made  fast  at 
any  point  b^'  a  screw;  in  the  upper  part  of 
this  slide  is  a  second  screw  passing  through  a 
slot  in  the  arm;  the  arm  is  also  of  brass  and 
terminates  in  a  curve  or  hook,  against  which 
rests  the  speculum  blade  not  in  use. 
Fig.  587.3  In   the   practice    of    gynecology  a  table* 

properly  arranged,  with  convenient  drawers  for  instruments,  is  an  excellent 
substitute  for  the  unsightly,  often  ill-adapted  and  expensive  chairs  that  are 
commonly  used.  The  patient  is  easily  and  comfortably  placed  in  the  semi- 
prone  position  (Fig.  588), i  or  on  the  back,  while  every  needed  appliance  is  at 
hand. 

2.  Vaginismus  ^  is  an  excessive  liypersesthesia  of  the  vulvar  out- 
let associated  with  such  involuntary   spasmodic  contraction   of  the 

1  J.  M.  Sims.        2  J.  B.  Hunter.        3  G.  Tiemann  &  Co.        *  J.  R.  Chadwick. 


THE    VAGINA. 


573 


sphincter  vaginae  as  to  prevent  coition;  violent  spasmodic  action  is 
produced  by  the  gentlest  touch,  as  of  a  camel's  hair  pencil  or  fine 
feather ;  though  all  jjarts  of  the  vaginal  outlet  are  sensitive,  it  is 
greatest  at  the  fourchette  when-  the  hyiiK'n  projt'Cts  upwards.  It 
may  be  associated  with  and  depend  upon  iuUamuiatiun  and  thicken- 


FiG.  588.1 

ing  of  the  hymen,  excoriations,  fissures,  neuromata,  caruncle  of  the 
meatus.  The  general  treatment  must  aim  to  remove  all  conditions 
which  are  found  to  cause  or  aggravate  the  spasm. 

Secure  complete  sexual  abstinence,  and  for  three  or  four  days  direct  a  tepid 
sitz  bath,  night  and  morning;  warm  local  bathing,  with  lead  water;  freedom 
from  friction  by  motion;  then  apply  arg.  nit.  10  to  20  grs.  to  3  i.  of  water  to 
the  parts:  after  eight  days  of  this  treatment,  insert  vaginal  suppositories  of  ext. 
belladonna  and  cocoa-butter  behind  the  hymen,  daily,  fur  two  or  three  weeks; 
then  commence  dilatation  with  graduated  glass  specula,  allowing  them  to  remain 
from  one  half  to  one  hour,  and  increasing  their  frequency.-  Other  useful  appli- 
cations are  iodifomi ;  ^  ointments  containing  atropine,  2  grs.  to  an  ounce  of  lard.* 
If  these  remedies  are  not  successful,  operative  measures  are  necessarv. 

Forcible  dilatation  may  first  be  employed  :  *  Give  an  anaesthetic, 
and  proceed  to  distend  the  ostium  vajiina;  with  the  thumbs,  in  the 
same  manner  as  the  sphincter  ani  is  dilated  (Fis.  390).  Or,  use  the 
trivalve  or  quadrivalve  speculum  for  distention.*     If  spasm  persist, 


1  Codman  &  Shurtleff. 
6  E.  J.  Tilt. 


-  Scanzoni.         *  Tarnier. 
*  T.  G.  Thomas. 


*  E.  R.  Ptaslee. 


574 


OPERATIVE  SURGERY. 


give  an  .ansestlietic  and  excise  the  remains  of  the  hymen  -with  scis- 
sors,^ and  incise  tlie  perineal  body  exactly  as  it  is  torn  in  parturition;  ^ 
introduce  the  dihiting  specuhnn  or  plug,  and  wear  it  for  a  week, 
changing  it  daily  for  cleanliness;  then  employ  copious  vaginal  injec- 
tions of  Avarm  water,  twice  daily. 

3.  Vesico-vaginal  fistula,^  following  parturition,  is  an  opening 
due  to  sloughing  into  tlie  bladder,  resulting  from  delay  in  delivery 
after  impaction  has  taken  place.  Tlie  only  remedy  is  closure  by 
suture.  The  secret  of  success  in  this  operation  lies  in  a  course  of 
preparatory  treatment  by  which  the  hypertrophied  and  indurated 
edges  of  the  fistula  have  recovered  a  natural  color  and  healthiness. 
The  course  of  treatment  may  require  many  weeks.  First,  the  de- 
posits upon  the  surfaces  of  the  fistula  must  be  removed  by  means  of 
a  soft  sponge ;  then  the  raw  surface  must  be  brushed  over  with  a 
weak  solution  of   nitrate  of  silver  about  every  fifth  day ;  copious 


Fig.  589. 


warm  water  injections  to  the  vasina  must  be  used  several  times 
daily;  and  warm  sitz  liaths  are  useful.  The  patient  being  in  proper 
condition,  place  her  on  the  table,  (Fig.  588)  on  her  left  side,  the  knees 
flexed  on  the  abdomen,  the  body  well  rolled  over  on  the  chest,  the 
left  arm  turned  up  over  the  back,  and  the  head  elevated  as  little  as 

possible.    Hav- 


ing decided  on 
the  direction  for 
closino;  the  fis- 


FiG.  590.8 


tula,  scarify  its  edges  by  seizing  with  a  tenaculum  (Fig.  590)  or  for- 
ceps (Fig.  589)  the  most  depending  point,  and  with  scissors  of 
proper  ciu-ve  (Fig.  591)  remove  the  inner  edge  in 
continuous  strip. 


It  requires  but  little  practice  to  make  this,  in  most  cases,  continuous  around 
the  entire  fistula  to  the  starting  point;  if  the  denuded  portion  is  not  of  sutRcient 
•width  more  sliould  be  removed;  just  outside  of  it  the  scarification  should  extend 
as  near  tlie  mucous  membrane  of  the  bladder  as  possible  without  involving  it.2 


1  J.  M.  Sims. 


2  T.  G.  Thomas. 


3  G.  Tiemann  &  Co. 


THE    VAdlXA. 


The  best  method  of  securing  the  edjes  of  the  fistula  is  In  the  sim- 
ple internipteil  suture.  The  needle  sliould  be  armc-d  witii  a  short 
silk  loop,  tied  with  a  half  knot  at  the  eye,  and  the 
wire  should  be  attacliL-d. 

The  needles  should  be  from  one  half  to  three  quarters  of 
an  inch  in  length,  round,  with  a  slight  curve  near  the  point, 
thickest  at  the  eye  and  countersunk  to  receive  tlie  thread;  this 
needle  makes  a  punctured  wound  which  the  wire  perfectly 
fills.  The  needle  should  be  inserted  with  suitable  forceps  (Fig. 
592).i 

The   point  of  the  tenaculum    should  be  introduced 
towards  the  fistula  at  a  convenient  distance  from  its 
vaccinal  edge,   then  by  a  rotation  of  the  hand  in  the 
opposite  direction  tlie   bladder  edge  of  the  fistula  Avill 
be  turned  out;  introduce  the  needle,  held  in 
the  forceps,  behind  the  tenaculum,  bringing 
its  point  out  just   at  the  bladder  surface, 
and  while  still  grasping  it  with  the  forceps 
withdraw  the  tenaculum,  pass  its  hook  over 
tlie  point  of  the  needle   to  make  counter 
])ressure.  while  it  is  advanced  as  far  as  the 
forceps  will  allow ;  then  seize  the  exposed 
portion  of  the  needle  and  draw  it  entirely 
through ;   seize  the  edge   on  the  opposite 
side  with  the  tenaculum,  in  the  same  man- 
ner and    introduce   the  needle  at  a  corre- 
sponding point  near  the   bladder  surface. 

sutures  should  be  applied  to  the  incli  (Fig. 
593),  ami  one  or  more  shouhl  be  passed  at  each 
extremity.  As  each  suture  is  introduced,  follow 
it  at  once  with  the  wire,  for  the  silk  soon  be- 
comes weakened  after  being  saturated  with  the 
blood  and  urine.  It  is  gener- 
ally most  convenient  to  secure 
first  the  suture  nearest  the 
outlet  of  the  vagina;  make 
siifiicient  traction  to  bring  the 
edges  of  the  fistula  together 
and  cut  off  the  excess  of  wire  (Fig.  594)  ;  introduce  the  looj)  within  the 

^^i=====:^    slit    of    the    shield 

■=^^saSS5SK^=^^^==''^  (Fig.     595),    and, 

Fio.  59.5.-  with    the    twisting 

forceps,  twist  the  loop  until  the  edges  of  the  wound  are  approxi- 

1  J.  M.  Sims.  ^  G.  Tlemann  &  Co. 


Fig.  592. 
As  a  rule,  four  or  five 


Fig.  ,593. 


576 


OPE  RATI  VE   SURGERY. 


mated,  but  not  strangulated ;  cut  each  suture  with  scissors  (Fig. 
596)  half  an  inch  from  the 
wound,  and  tui"n  the  ends 
flatwise  by  drawing  them 
over  the  hook.  The  sigmoid 
catheter  (Fig.  597)  is  now  in- 
troduced into  the  bladder, 
and  rest  upon  the  back,  se- 
cured with  quiet ;  the  vagina 
must  be  syringed  with  soapod- 
watcr,  daily,  and  simple  diet 
enforced;  the  sutures  should 
be  removed  about  the  tenth 
day. 

4.  Tumors  of 


the 


vagina,^ 


solid  and  non- 
malignant,     are 

rare ;     they    are 

usually     fibroids 

or  fi  b  r  o  -  m  y  o  - 

mata,  rarely  pure 

sarcom  ata ;    they 

may  spring  from 

any  part  of  the  vagina,  appear  at  any  age,  gi-ow  slowly  and  with- 
out inconvenience.  Their 
removal  is  attended  with 
haamorrhage,  and  hence  the 
galvano-caustic,  or  dcraseur^ 
is  required. 


Fig.  596. 


Fig.  597.2 


CHAPTER    LVI. 
THE   VULVA. 

The  vulva  is  a  general  term  which  includes  all  the  external  parts 
of  the  generative  organs  of  the  female.'* 

1.  Adhesion  of  the  labia,^  the  most  common  deformity  met  with, 
exists  when  the  parts  adhere  together  just  at  the  nymplije,  or  in 
front  of  them,  close  to  the  meatus  urethrje;  it  appears  as  a  gray- 
i.sh-looking  septum,  usually  complete.  The  treatment  should  be  im- 
mediate ruptui-e,  for  if  the  membrane  be  allowed  to  remain  it  may 

1  Neugebauer.        2  Q.  Tieniann  &  Co.         °  J.  M.  Sims.        '^  Quain's  Anat. 
s  T.  Holmes;  A.  Johnson. 


THE    VL'LVA.  iul 

become  thicker  and  require  dissection  ;  after  rnpture  the  parts  must 
be  iiiaintJviiK'd  wcW  npciicd. 

2.  Imperforate  hymen^  iiiiiy  he  recojriiized  in  tlie  child,  but  gen- 
erally it  is  not  discovered  until  jjuberty.  It  appears  as  a  membrane 
stretched  across  a  well-formed  vagina,  within  an  inch  or  two  of  the 
labia,  and  more  or  less  thick  and  unyielding.  An  effort  should 
always  be  made  to  determine  its  thickness;  and  also  whether  the 
uterus  is  present,  by  examining  iis  to  the  amount  of  space  between 
the  bladder  and  rectum  ;  '^  if  the  sp:ice  is  slight,  there  is  reason  to 
believe  that  there  is  no  uterus,  and  an  operation  may  be  deferred. 
But  an  early  operation  is  much  safer  than  one  undertaken  after  men- 
struation has  begun,  and  should  be  performed,  if  necessary.  In 
children,  the  membrane  may  be  readily  ruptured  ;  but  at  puberty 
the  operation  is  attended  by  much  danger  to  life. 

In  a  very  considerable  proportion  of  cases,  fatal  peritonitis  ensues  in  a  few 
days,  due,  apparently,  to  tlie  escape  of  menstrual  fluid  through  the  Fallopian 
tubes.3 

Operate  thus  :  place  the  patient  on  the  back,  with  the  thighs 
flexed  ;  the  exact  position  of  the  centre  of  the  vagina  above  being 
made  out,  direct  the  patient  to  force  down ;  when  the  occluding 
structure  is  distended,  introduce  a  bistoury  into  its  centre  and  en- 
large the  opening  so  as  to  admit  the  finger  which  will  act  as  a  di- 
rector in  making  free  crucial  incisions;  if  there  is  a  redundancy  of 
membrane,  dissect  away  part  of  it ;  care  must  be  taken,  for  a  week  or 
two,  to  prevent  contraction. 

3.  Thrombus,  blood-clot,  resulting  from  injury,  forms  in  the  labia; 
in  time  it  undergoes  softening,  and  an  abscess  results.  The  early 
treatment  should  be  cold,  but  when  suppuration  occurs  poultices 
must  be  applied,  and  the  abscess  opened  when  fully  formed. 

4.  Hypertrophies  of  the  labia  commence  usually  in  inflamma- 
tory oedema  produced  by  the  irritation  of  gonorrheal  discharge  or 
mucous  tubercle  ;  they  consist  only  of  hypertrophied  cutaneous  tis- 
sue, and  when  large  increase  in  consequence  of  the  mechanical  im- 
pediments to  the  circulation.  They  should  be  removed  early,  and, 
owing  to  the  tendency  to  excessive  haMnorrhage,  the  base  should  be 
transfixed  by  harelip  pins  with  twisted  ligatures,  after  all  bleeding 
vessels  have  been  li'^ated. 

5.  Epithelioma  ^  is  the  chief  form  of  malignant  disease  of  these 
parts  ;  it  appears  as  an  irregular,  undermine<l,  indui'ated  edge,  an  un- 
healthy gray  surface,  an<l  a  tendency  to  the  production  of  warty 
granulations  ;  the  prognosis  is  very  unfavorable,  owing  to  the  ten- 

1  J.  Hutchinson.  2  ']'.  Hohnes.  8  Uernutz. 

37 


578 


OPERATIVE  SURGERY. 


dency  to  rapid  absorption.  Removal  by  the  knife  or  caustics  is  the 
only  remedy. 

6.  Laceration  of  the  vulva  and  perineum  occurs  during  the 
last  act  of  labor,  and  may  be  due  to  (1)  anatomical  conformations, 
as  a  too  straight  sacrum,  a  too  sharp  curve  forward  of  the  vagina, 
extreme  smallness  of  vulva  ;  (2)  excessive  size  of  the  head  of  the 
child ;  (3)  peculiarities  of  labor,  as  face  presentations,  incomplete  or 
excessive  flexion,  too  rapid  or  too  slow.^  The  extent  of  laceration 
may  vary  from  a  slight  fissure  to  complete  division  of  the  perineum 
and  sphincter  ani.- 

By  laceration  of  the  perineum  the  ischio-perineal  ligaments  are  di- 
vided, and  then  the  transverse  perinei  muscles  and  other  attachments 
draw  the  sides  of  the  vaginal  outlet  apart ;  the  connective  tissue  of 
the  pelvis  can  therefore  no  longer  exercise  the  same  sustaining  power, 
nor  that  little  in  the  same  direction  as  heretofore,  so  that  the  canal 
now  remains  patulous;  there  remains  no  support  to  the  uterus  while 
the  woman  is  in  the  upright  position,  except  through  the  connective 
tissue  and  (he  utero-sacral  ligaments;  as  she  stands  erect,  in  this 
condition,  a  perpendicular  line,  from  the  front  of  the  sphincter  ani, 
would  pass  through  the  posterior  lip  of  the  uterus,  or  even  behind  it; 
the  uterus  is  thus  suspen'ded  over  a  constantly  dilated  and  relaxed 
cavity,  and  with  this  state  of  things,  before  a  very  long  period 
complete  prolapse  of  the  uterus  will  take  take  place.^  In  the  normal 
relation  of  parts,  it  is  seen  that  the  perineum  and  recto-vesical  sep- 
tum sustain  the  uterus  with  great  firm- 
ness (Fig.  598).* 

Tlie  laceration  may  even  involve  only  the 
vaginal  surface  without  extending  through  to 
the  ."ikin,  and  this  is  done  by  splitting  through 
a  fold  of  vaginal  tissue  which  may  be  found  in 
advance  of  the  child's  head  just  before  birth; 
this  lesion  seems  to  extend  deep  enough  to  di- 
vide the  central  attachment  of  the  ischio-peri- 
neal ligaments,  with  the  effect  of  leaving  the 
vaginal  outlet  flaccid  and  depriving  it  of  its 
proper  sui>port.  The  inipoi'tance  of  having  the 
perineum  intact,  and  its  influence  on  the 
healthy  condition  of  the  nervous  system,  is  not 
fully  appreciated;  when  extensively  lacerated, 
and  prolapse  occurs,  it  is  easy  to  recognize  an 
obvious  cause  of  suffering;  but  cases  are  met  with  complicated  by  nervous  dis- 
turbances, due  to  the  existence  of  this  lesion,  without  prolapse;  this  condition 
will  sometimes  be  accompanied  by  a  general  irritability  which  cannot  be  traced 
to  any  other  local  cause,  and  is  onh'  relieved  by  restoring  the  perineum;  there 
are  instances  in  which  the  existence  of  even  a  scar  on  the  perineum  excited  so 


Fig.  598. 


1  B.  F.  Barker. 


2  I.  B.  Brown. 


3  T.  A.  Emmet. 


*  Savage. 


THE    VULVA.  579 

much  reflex  irritation  as  to  entirely  change  the  disposition  of  the  woman,  and 
yet  she  was  not  conscious  of  any  local  difficulty.^ 

WhenevLT  tlu'  pL'i'inemn  has  been  lacerated  so  tliat  tlic  proper  de- 
gree of  support  to  tlie  va'^inal  walls  is  no  lon!:rer  exerted,  there  can 
be  no  doubt  as  to  the  necessity  fur  an  operation  to  restore  the  parts 
to  their  original  condition  ;  there  arc  cases,  however,  where  a  doubt 
may  remain  even  after  a  careful  examination  ;  but  if,  after  the  oc- 
currence of  the  accident,  the  vagina  becomes  a  patulous  canal,  so 
that  the  air  enters  and  is  displaced  from  the  passage  with  every 
movement  of  the  body,  the  operation  is  required.^ 

It  is  yet  a  mooted  question,  how  soon  after  the  injury  the  operation 
should  be  performed ;  but  when  the  laceration  has  extended  through 
the  sphincter,  the  ])arts  should  be  brought  together  immediately  after 
delivery,  in  every  instance  when  it  is  possible  to  do  so. 

It  is  true  that  the  lociiial  discharge  is  poisonous  to  a  healing  surface,  yet  a 
larpe  numher  of  these  operations  would  be  successful  with  a  little  additional 
care:  the  operation  would  be  comparatively  a  simple  one,  and  it  would  be  un- 
necessary to  pass  the  suture  beliind  the  muscle;  something  would  be  gained  in 
every  case,  and  support  would  be  given  to  the  uterus,  for  a  while  at  least,  until 
it  had  become  somewhat  reduced  in  size,  and  time  gained  for  the  overstretched 
vaginal  tissues  to  recover  in  part  their  tone;  a  week  even  thus  gained,  in  giving 
a  proper  support  to  the  parts,  may  be  the  means  of  saving  the  patient  from  the 
necessity  of  undergoing  treatment  for  months;  this  she  may  be  spared,  even  if 
the  operation  itself  should  fail;  if  the  condition  of  the  patient,  after  delivery,  is 
too  critical  to  admit  of  the  additional  operation  for  bringing  together  the  edges 
of  an  extensive  laceration  through  the  septum,  it  is  advisable  to  introduce  the 
deep  perineal  sutures,  to  include  as  much  of  the  septum  beyond  the  muscle  as  is 
possible  ;  these  sutures  can  be  rapiilly  introduced,  and  without  an}'  special  care 
beyond  including  a  liberal  amount  of  tissue;  if  a  union  of  the  perineum  is  thus 
gained,  with  a  portion  of  the  se|)tuni  beyond  the  sphincter,  but  a  small  recto- 
vaginal fistula  will  remain;  this  may  jirove  a  discomf3rt,  but  its  closure  may  be 
safely  deferred  ;  this  little  opening  may  be  closed  by  dividing  the  perineum 
and  sphincter  ani  by  means  of  a  pair  of  scissors,  which  permits  the  edges  of  the 
opening  to  be  thoroughly  denuded,  a  procedure  otherwise  very  diliicult;  the 
parts  can  then  be  brought  together  and  treated  in  every  respect  as  if  it  were  a 
case  of  laceration  in  which  the  surfaces  had  just  been  freshened  i  Or,  the  open- 
ing may  be  closed  after  denuding  the  edges,  by  passing  the  sutures  around  the 
fistula  from  the  perineum;  with  the  finger  in  the  rectum  as  a  guide,  a  suture 
is  passed  so  as  to  close  the  edge  on  the  rectal  side,  and  another  above  for  the 
vaginal  border;  the  lower  suture  includes  so  much  of  the  sphincter  ani  muscle, 
that  its  action  in  the  ujiper  part  is  controlled;  by  this  means  the  fistula  closes, 
a  result  whicii  is  almost  impossil)le  to  be  obtained  under  ordinary  circumstances, 
since  the  outer  fibres  of  the  muscle  form  one  side  of  the  fistulous  opening.i 

When  an  operation  cannot  be  resorted  to  immediately  after  the 

injury,  the  knees  should  be  kept  tied  together,  the  urine  properly 

drawn,  and  the  greatest  care  given,  by  cleanliness,  to  free  the  parts 

from  irritation;  at  the  reception  of  the  injury,  the  rent  through  the 

1  T.  A.  Emmet. 


580  OPERATIVE  SURGERY. 

septum  is  more  extensive  than  after  the  edges  have  cicatrized,  there- 
fore, if  proper  care  be  taken,  by  frequent  injections  of  tepid  water, 
to  keep  the  parts  free  from  irritating  discharges,  the  edges  will  unite 
to  within  a  short  distance  of  the  sphincter;  before  the  patient  is  al- 
lowed to  assume  the  upright  position,  some  mechanical  support  must 
be  resorted  to  for  the  purpose  of  lifting  the  uterus  from  the  floor  of 
the  pelvis,  and  also  to  keep  the  organ  partially  anteverted,  so  that 
there  may  be  no  prolapse  of  the  vaginal  walls;  after  she  has  recovered 
her  strength,  if  the  child  has  been  still-born,  the  operation  should  be 
performed  without  further  delay;  for  the  welfare  of  the  child,  if  she 
be  nursing,  the  operation  should  be  deferred  until  it  is  old  enough  to 
be  weaned  with  safety  ;  but,  at  the  same  time,  we  must  take  into 
consideration  the  condition  of  the  mother,  as  to  how  long  she  may  be 
safely  subjected  to  the  delay,  with  the  uterus  well  supported.^ 

]f  the  sphincter  ani  is  not  involved,  proceed  as  follows:  ^  Place 
the  patient  on  a  narrow  table,  and  administer  the  anaesthetic  ;  now 
flex  both  legs  on  the  abdomen,  to  be  thus  held  by  an  assistant 
after  the  body  of  the  patient  has  been  drawn  down  to  the  edge 
of  the  table ;  in  separating  the  labia,  the  fingers  of  one  assistant 
must  be  placed  directly  opposite  those  of  the  other;  this  is  necessary, 
for  if  not  on  the  same  line,  or  if  unequal  traction  be  made,  it  would 
be  difficult  to  avoid  denuding  the  side  of  one  labium  higher  than  that 
of  the  other.  Commence  the  operation  by  removing  the  mucous 
membrane  at  the  most  dependent  portion,  and  advance  from  below 
upwards,  and  thus  avoid  the  flow  of  blood  over  the  surface  to  be  re- 
moved. 

The  mucnus  membrane  is  cau£;ht  up  on  the  point  of  a  tenaculum,  and  with  a 
pair  of  properly  curved  scissors  it  should  be  removed  in  a  horizontal  strip  run- 
ning from  side  to  side;  if  the  operator  is  ambidextrous,  the  whole  surface  niaj'' 
be  removed  in  one  continuous  strip;  by  using  a  pair  of  scissors  with  a  different 
curve  to  turn  the  point  at  one  labium,  we  can  extend  the  line  back  again  upon 
the  posterior  wall  of  the  vagina,  and  from  there  to  the  opposite  labium,  and 
then  going  over  the  same  course  again  just  above  the  preceding  one  (Fig.  601). 

Determine  the  extent  to  which  the  denudation  is  to  be  carried 
on  the  posterior  wall,  and  mark  it  by  removing,  as  a  guide,  a  small 
portion  of  tissue  from  the  median  line;  the  advantage  of  the  scis- 
sors in  this  operation  cannot  be  questioned,  for  with  the  utmost  dex- 
terity and  quickness,  the  parts  cannot  be  freshened  and  brought  to- 
gether without  a  great  loss  of  blood,  and  the  amount  of  bleeding  is 
less  from  the  use  of  scissors,  and  with  them  the  parts  can  be  denuded 
in  a  much  shorter  time  than  with  the  knife. 

Use  a  thick,  straight  sewing  needle,  from  an  inch  and  a  half  to 
two  inches  in  length,  with  a  large  eye  for  introducing  the  silk  Ioojd, 
1  T.  A.  Emmet. 


THE    VULVA. 


581 


to  which  the  wire  is  to  be  afterwards  attached  before  beino;  drawn 
through:  the  iiuh'x  finger  must  be  passed  into  the  rectum  to  ap- 
preciate the  course  and  facilitate  the  passage  of  the  needle,  and, 
at  the  same  time,  it  will  protect  the  posterior  wall  of  the  bowel 
from  becoming  transfixcil;  as  the  tissues  of  the  recto-vaginal  septum 
are  thus  lifted  up  on  the  j)oint  of  the  finger  the  course  to  be  followed 
by  the  needle  becomes  nearly  straight.  The  central  letter  c  (Fig. 
699)  is  at  the  crest  of  the  rectocele;  the 
surface  lias  been  denuded  from  the 
edge  of  the  sjihincter  ani  muscle  up 
each  labium  to  the  remains  of  the  car- 
uncuUe,  and  across  on  the  posterior 
■wall  of  the  vagina  to  the  extent  of  the 
rectocele.  IntrocUice  the  first  suture 
nearest  to  the  edge  of  the  anus,  and 
its  course  through  the  recto-vaginal 
septum  is  indicated  by  the  dotted  line. 
The  same  explanation  in  regard  to 
their  course  is  applicable  to  the  other 
numbered  sutures.  The  course  of  the 
suture  D  is  shown  on  its  exit,  from 
behind  one  labium,  to  enter  at  d  on 
the  upper  edge  of  the  denuded  surface 
over  the  posterior  wall  of  the  vagina. 
This  is  essentially  the  last  suture  in- 
troduced to  secure  this  surface,  and 
does  not  include  more  than  an  inch  before  it  passes  to  the  opposite 
labium.  The  course  of  the  uppermost  suture,  c,  is  through  tlie  la- 
bium, just  in  line  with  the  limit  of  the  freshened  surface.  It  is  then 
made  to  catch  up  a  small  portion  of  the  vaginal  tissue  at  c,  beyond 
the  denuded  surface  on  the  recto-vaginal  wall,  when  it  also  passes  to 
the  opposite  labium.  Leave  each  twisted  suture  about  three  inches 
in  length,  and  when  the  operation  has  been  completed,  secure  the 
ends  of  all  of  these  together,  like  the  radii  of  an  open  fan  ;  these 
ends  may  be  bound  together  by  slipjiing  over  them  a  short  section  of 
rubber  tubing.  The  patient  must  be  kept  in  bed  with  her  knees  tied 
together  and  a  soft  pad  between  them ;  the  urine  should  be  drawn 
with  care,  to  prevent  it  from  running  over  the  healing  surfaces;  this 
can  best  be  done  by  flexing  the  legs  over  the  abdomen,  as  at  the  time 
of  the  operation,  but  without  removing  the  bandage  from  the  knees; 
then,  with  a  strip  of  soft  cloih  covering  the  index  finger  of  the  left 
haml,  the  parts  maybe  protected  by  jdacing  this  beneath  the  urethra 
as  the  catheter  is  withdrawn.  The  ailditional  precaution  should  also 
be  taken  to  close  the  end  of  the  instrument  by  keeping  the  finger  over 


Fig.  599. 


582  OPERATIVE  SURGERY. 

it.  Should  the  urethra  become  irritable,  or  circunislauces  occur  in 
which  the  catheter  cannot  be  employed,  it  will  be  necessary  to  observe 
more  than  the  usual  cleanliness;  after  the  bladder  has  been  emptied, 
and  before  removing  the  bed-pan,  the  nurse  must  throw  a  pint  or 
more  of  tepid  water  into  the  vagina.  The  nozzle  of  the  syringe 
should  be  carefully  introduced  close  to  the  urethra,  and  during  the 
administration  of  the  injection  it  is  to  be  held  in  this  position  so  as 
not  to  come  in  contact  with  the  line  of  union.  Opium  should  not  be 
used  in  any  form,  unless  the  necessity  be  very  great,  and  even  then 
it  is  well  to  seek  some  substitute  foi"  it.  The  position  of  the  patient 
may  be  changed  from  the  back  to  either  side  without  injury  to  the 
sutures,  so  long  as  the  limbs  are  kept  together.  The  parts  will  liave 
become  sufliciently  healed  by  the  seventh  day  for  the  removal  of  the 
sutures;  no  advantage  is  to  be  gained  by  leaving  them  for  a  longer 
time,  but,  on  the  contrary,  there  will  be  risk  from  inflammation  fol- 
lowing some  accidental  injury;  to  remove  the  sutures,  it  will  be  nec- 
essary to  place  the  patient  on  a  table,  and  on  her  back,  with  the 
feet  drawn  up;  as  it  would  not  be  advisable  to  separate  the  parts  to 
bring  the  loops  into  view,  it  will  be  necessary  to  trust  somewhat  to 
the  sense  of  touch ;  first  remove  the  piece  of  tubing  by  cutting 
through  the  mass  of  sutures,  which  will  free  them  all;  then  the  low- 
est one  may  be  grasped  by  a  pair  of  foix-eps  and  gently  turned  to  the 
right  side,  while  the  blades  of  a  pair  of  sharp-pointed  scissors  are 
passed  down  along  the  left  side  of  the  suture  in  search  of  the  loop. 
The  parts  can  be  supj)orted  and  also  protected  by  an  assistant  press- 
ing or  holding  the  labia  together  until  all  the  sutures  have  been 
withdrawn.  For  a  week  after  the  removal  of  the  sutures,  the  limbs 
shoidd  remain  bound  together,  then  the  bandage  may  be  thrown 
aside,  and  only  used  at  night  for  a  short  time  longer.  It  should  be 
the  rule  that  the  patient  be  not  allowed  to  assume  the  upright  posi- 
tion for  two  weeks. 

7.  Laceration  throiigh  the  sphincter  ani  ^  is  but  an  extension  of 
the  laceration  of  the  perineum.  It  is,  however,  without  any  neces- 
sary bearing  on  the  study  of  prolapse,  since  advice  is  generally 
sought  for  early,  and  the  injury  repaired  before  sulHcient  time  has 
elapsed  for  the  case  to  become  thus  complicated.  Both  conditions 
are  but  different  degrees  of  the  same  injury,  and  the  same  operation 
also,  varying  only  in  detail,  is  required  for  the  relief  of  both.  The 
necessary  dissection  of  the  surfaces  al)out  to  be  united  must  be  made 
as  before,  and  when  completed  the  wound  will  appear  as  represented 
(Fig.  601  ).2 

Wlien  the  |)eiiiieuin  and  the  muscular  ring  forming  the  sphincter  ani  liave 
been  lacerated,  a  gaping  triangular  opening  Is  left;   the  base  of  this  opening 
1  T.  A.  Emmet.  2  Q.  G.  Bantock. 


THE    VULVA. 


583 


would  be  formed  by  the  lacerated 
muscle  and  the  apex  by  the  limit 
of  the  laceration  tiirouph  the 
recto  vatjiiial  septum;  gradually 
the  tibres  which  formed  the  inner 
surface  of  the  circle,  when  the 
muscle  was  in  its  integrity,  will 
have  shortened  more  than  those 
on  the  outer  margin  which  re- 
main attaelied  to  the  neighboring  tissues  ;  the  diagram  (tig.  GOO)  shows  the 
corners  rounded  off.  and  the  muscular  tibre  under  the  mucous  membrane  of  the 
rectum  contracted  more  than  any  other  portion  ;  a 
convex  surface  is  presented  by  the  shortening  of 
the  inner  fibres  from  the  dotted  outline,  represent- 
ing a  parallelogram,  which  was  the  original  shape 
of  the  muscle  just  after  it  was  ruptured.  .After  the 
edges  of  the  muscle  have  been  properly  freshened, 
the  most  important  step  in  the  0|>eration  will  be 
the  manner  of  introducing  the  first  suture,  in  its 
relation  to  the  edges  of  the  divided  muscle.  If  the 
first  suture  be  entered  on  the  line  a  little  outside  of 
A  B  (Fig.  600),  and  at  the  point  which  would  seem 
the  most  appropriate,  but  a  small  portion  of  the 
muscle  could  be  approximated.  P'ig.  602  exhibits 
tlie  condition  of  the  parts,  when  they  have  been 
thus  secured  by  a  suture  entered  from  a  b,  with  incontinence  as  the  conse- 
quence. Introduce,  however,  the  suture  at  some  distance 
behind  the  edge  of  the  muscle,  as  the  |)oints  c  n  (Fig. 
600).  and  a  difiVrent  result  will  be  obtained;  a  glance 
at  Fig.  603  will  show  that,  on  securing  the  sutures,  the 
divided  edges  of  the  sphinc- 
ter will  be  turned  up  and 
brought  in  perfect  apposi- 
tion; When  the  suture  is 
passed  from  behind  the 
edges  of  the  muscle  and 
around  the  laceration,  in 
the  recto-vaginal  septum, 
the  edges  of  the  muscle 
must  be  turned  up  on  tight- 
ening. 

The  nceossary  positioti  of  the  patient  for  the  operation,  with  all 
other  details,  are  essentially  the  same  as  described  for  eloslnfr  a  lacer- 
ation of  tln>  perineum.  The  surfaces  which  liave  been  lacerated, 
and  are  afrain  to  be  freshened,  are  prenerally  well  mapped  out  by  a 
slight  cicatricial  glaze.  Under  ordinary  circumstances,  unless  slough- 
ing has  occurred,  there  can  be  but  little  dillicidty  in  determining  the 
extent.  As  the  edges  of  the  laceration  through  the  septum  have  to 
be  freshened  with  care,  it  is  essential  to  commence  tlie  denuding 
from  the  most  depen<ling  point,  and  by  this  means  escape  the  an- 
noyance of  i)Iooil  flowing  over  the  p;irts. 


Fig.  002. 


Fig.  603. 


584 


OPERATIVE  SURGERY. 


If  we  examine  carefully  the  extremities  of  the  lacerated  muscle,  we  shall  find 
a  slight  pit  or  depression  at  each  end,  which  has  been  caused  by  the  contraction 
of  a  portion  of  its  tibres.  It  is  necessary  to  freshen  these  surfaces,  for  by  so 
doing  we  denude  the  ends  of  the  muscle  along  the  spaces  between  the  dotted 
angles,  shown  in  Fig.  600.  At  the  commencement  of  the  operation  a  portion  of 
the  tissues  at  one  of  these  points  must  be  seized  with  a  tenaculum  and  with  a 
pair  of  scissors  removed,  together  with  a  narrow  strip  entirely  around  the  lacer- 
ation to  the  opposite  end  of  the  muscle.  This  strip  must  be  removed  as  close  to 
the  edge  of  tiie  rectal  mucous  membrane  as  can  be  done  without  wounding  it. 
Whenever  the  edges  of  the  laceration,  in  the  recto- vaginal  septum,  are  found 
terminating  in  a  thin  beveled  edge,  it  will  be  necessary  to  gain  the  needed 
width  by  removing  a  sufficient  portion  of  the  vaginal  mucous  membrane. 

The  needle  is  to  be  introiluced  behind  the  edge  of  the  muscle  to 
the  left,  at  the  point  D,  Fig.  600.  It  is  then  made  to  sweep  around 
the  angle  of  the  laceration  in  the  septum  to  the  jjoint  of  exit  at  c, 
and  this  is  done  by  gradually  rotating  the  forceps  with  a  movement 
of  the  wrist.  As  in  laceration  of  the  perineum,  it  is  necessary 
that  the  index  finger  of  the  left  hand  be  introiluced  into  the  rectum 
to  serve  as  a  guide.  As  the  point  of  the  needle  punctures  the  skin 
in  its  exit,  the  finger  may  be  withdrawn  from  the  rectum  to  aiil  the 
passage  of  the  needle.  This  can  be  done  by  the  counter  pressure  of 
a  blunt  hook,  or  by  sliding  back  the  tissues  sufiiciently  with  the  fin- 
gers, for  the  needle  to  be  seized  by  the  forceps  and  drawn  through. 
The  second  suture  is  to  be  introduced  just 
outside  of  the  end  of  the  muscle,  and  in 
the  same  phine  with  the  divided  rectal 
edge  of  the  laceration.  The  third  suture 
is  to  secure  the  vaginal  edge  of  the  lacer- 
ation. It  should  be  made  to  include  the 
tissues  liberally,  and  to  sweep  around  the 
angle  of  the  laceration  at  some  distance 
be}ond  the  coui'se  of  the  first  and  second 
suture,  this  is  necessary,  since  this  suture 
is  the  one  most  liable  to  cut  through  the 
recto-vaginal  septum  and  leave  a  fistula. 
The  other  sutures  are  to  be  introduced  as 
in  a  case  of  simple  laceration  of  the  per- 
ineum (Fig.  604).  It  is  necessary  to  secure 
first  the  lowest  suture,  c  d  (Fig.  600).  This  is  done  by  seizing  the 
ends  of  the  wire  at  a  proper  distance,  so  that  the  fingers  may  be  used 
to  slide  the  tissues  firmly  down  on  the  suture,  as  moderate  traction 
on  the  wire,  is  made  at  the  same  time  with  the  hands.  The  suture 
is  then  secured,  without  relaxing  the  traction,  by  several  half  turns 
made  on  reversing  the  position  of  the  hands  from  one  side  to  the 
other.  Each  suture  is  thus  in  turn  secured  from  below  upward. 
1  G.  C.  Bantock. 


Fig.  G04.1 


Tin:   MAMMAHY   C LANDS.  585 

Tilt'  ])arts  sliouM  hv  just  l)roui;lit  in  apposition,  an<l  no  more,  for 
in  a  few  hours  there  will  be  sudieient  swellinjf  to  force  the  tissues  in 
close  contact.     The  after-treatment  is  the  same  as  that  tjiven  above. 


CHAPTER    LVIL 
THE   MAMMARY   GLANDS. 

These  glands,  the  organs  of  lactation  in  the  female,  arc  accessory 
parts  of  the  reproductive  system;  when  fully  developed,  they  form, 
with  the  integuments  and  a  considerable  quantity  of  fat,  two  rounded 
eminences,  the  breasts,  placed  on  each  side  on  the  front  of  the  tho- 
rax; the  base  of  the  gland  is  nearly  circular,  flattened,  or  slightly 
concave,  its  largest  diameter  being  directed  upwards  and  outwards; 
it  rests  upon  the  pectoral  muscle,  to  which  it  is  connected  by  a  layer 
of  areolar  tissue.^ 

1.  lufiammation  of  the  breast,^  mastitis,  may  occur  in  three  forms. 
(1.)  The  subcutaneous  connective  tissue  may  alone  be  affected  ;  this 
form  is  often  caused  by  bruising  or  irritation,  as  in  rude  attempts  to 
use  a  breast  pump,  the  symptoms  and  appearances  being  those  of 
phlegmonous  inflammation.  The  treatment,  at  first,  must  be  paint- 
ing with  iodine,  avoidance  of  rubbing,  and  of  bruising,  while  nurs- 
ing, aconite  if  the  fever  is  high  ;  anodynes  to  relieve  pain;  if  sup- 
puration occur,  apply  hot  poultices,  or  cloths  soaked  in  hot  water  and 
covered  by  oiled  silk;  evacuate  pus,  when  detected,  avoiding  the 
areola?,  to  prevent  a  cicatrix  which  would  retract  the  nij)j)le.  (2.) 
The  gland  structure  may  inflame  from  lacteal  obstruction  or  engorge- 
ment; it  is  marked  by  a  nodulated  induration,  exqiusitely  tender, 
and  very  painful,  rendering  nursing  distressing;  the  constitutional 
symptoms  depend  upon  the  individual;  if  she  is  robust,  the  fever  is 
high  and  the  course  of  the  disease  rapid,  but  if  she  is  feeble,  the 
fever  is  less  and  the  course  chronic.  The  early  local  treatment  is 
relief  to  the  engorgement  by  gently  rubbing  the  lump  with  the  fin- 
gers lubricated  with  olive  oil  until  the  mass  disappears,  avoidance 
of  nursing  and  the  relief  of  the  breast  by  artificial  means,  support- 
ing the  breast  by  a  broad  bandage  passed  under  it  and  around  the 
neck;  ext.  belladonna,  Avell  rubbed  in,  to  relieve  pain,  relax  tissues, 
and  diminish  the  secretion  of  milk;  if  suppuration  is  evident  hot 
poultices  must  be  applied,  and  the  abscess  opened  when  fluctuation 
is  distinct;  too  early  incision  is  liable  to  involve  the  milk  tubes.  If 
the  fever  is  high,  give  aconite  to  the  robust,  and  saline  laxatives 
and  quinine,  to  the  more  feeble;  opium,  as  Dover  or  Tully  powder, 
1  Quain's  Anatomy.  2  jj.  p.  Barker. 


586 


OPERATIVE  SURGERY. 


or  the  bromides,  are  always  useful.  (3).  The  inflammation  may  at- 
tack the  sul)nlan(lular  conneetive  tissue;  the  breast  is  greatly  en- 
larged and  heavy,  but  smooth,  and  not  markedly  tender;  there  are 
irregular  chills  and  fever,  with  intervals  of  persjoii'atiun.  The  treat- 
ment is  avoiilance  of  bruising,  as  rubbing  the  breast,  but  nursing 
must  be  continued  ;  support  of  the  gland  by  the  bandage;  poulticing 
at  the  point  where  pus  is  forming;  evacuation  of  pus  by  puncture 
without  wounding  the  gland  structure;  the  general  treatment  is  the 
same  as  that  given  in  the  other  forms  of  inflammation. 

2.  Abscess  of  the  breast  is  liable  to  remain  in  a  chronic  form 
after  the  glandular  and  subglandular  varieties,  which  are  sources  of 
great  annoyance  and  continued  ill  health. 

Their  chronicity  depends  upon  the  fact  that  the  abscess-cavities  have  no  di- 
rect outlet  for  tiieir  contents;  the  escape  from  existing  sinuses  is  chiefly  the 
overflow;  from  time  to  time  the  corrosive  secretion  opens  new  and  more  direct 
outlets,  and  not  unfrequently  a  single  abscess  is  found  to  liave  several  sinuses, 
or  cicatrices  of  sinuses  which  have  healed  as  n*i\f  openings  formed. 

The  treatment  by  incision,  to  lay  open  the  abscess,  is  unnecessarily 
severe,  ami  is  often  followed  by  deep  cicatrices  which  destroy  the 
function  of  portions  of  the  breast  ;  systematic  strapping  is  far  more 
useful,  for  by  compressing  the  abscess-walls  so  as  to  force  out  the 
contents  and  place  the  opposing  surfaces  in  apposition,  union  often 
promptly  follows,  and  the  cure  is  complete. 

The  straps  should  be  cut  sufficiently  long  to  pass  from  the  opposite  shoulder, 

under  the  breast  to  the  point  of  starting, 
and  in  width  about  two  inches;  having 
the  breast  firmly  raised,  apply  the  end  of 
tiie  strap  over  the  opposite  siioulder,  and 
pass  it  under  the  breast  and  axilla,  and 
over  the  back  to  the  place  of  departure, 
allowing  the  ends  to  overlap  (Fig.  60.5). 
Each  successive  strap  should  overlap  the 
preceding  towards  the  nipple,  until  the 
required  compression  or  support  is  at- 
tained. 


Fig.  605. 


A  still  more  simple  and  effective 
method  is   pressure  with  the  com- 
pressed sponge,  as  follows:  ^  — 

Select  a  soft  sponge,  larger  than  the  breast,  cup-shaped,  and  three  or  four 
inches  in  thickness  when  wet;  wash  it  and  place  it  between  two  boards  under 
a  weight  of  fifty  pounds;  in  a  few  hours  it  will  be  dry  and  reduced  to  the  thick- 
ness of  the  hand;  place  it  upon  the  breast,  the  cup  being  over  the  nipple,  and 
bind  it  firmly  in  position  with  repeated  turns  of  the  bandage  around  the  body 
and  over  the  opposite  shoulder;  if  the  sponge  is  too  harsh,  apply  a  layer  of  lint 
or  soft  cloth  first  to  the  breast;  leave  a  small  portion  of  sponge  projecting  above 

1  J.  P.  Batchelder. 


THE  MAMMARY   GLAXDS.  587 

the  highest  turn  of  the  bandage;  now  apply  warm  water  to  this  p<iint  of  the 
sponge  and  continue  until  the  entire  sponge  becomes  (saturated  under  the  band- 
ages; the  swelling  of  the  sponge  evacuates  by  the  gentlest  and  most  uniform 
pressure  the  cavity,  presses  the  walls  together  and  maintains  them  till  union 
takes  place;  the  water  njust  be  reapplied  as  often  as  ihe  sponge  becomes  dry; 
the  dressings  must  be  renewed  on  the  third  day,  unless  the  abscess  has  healed. 

3.  The  nipple  and  areola^  are  liable  to  be  affected  in  women 
forty  years  and  iipwanLs,  with  a  chronic  affection  of  the  skin,  which 
often  precedes  cancer  of  the  deeper  parts  of  the  <;land;  it  a[»pears  as 
a  Horid,  intensely  red,  raw  surface,  very  finely  granular,  as  if  nearly 
the  whole  thickness  of  the  epidermis  were  removed,  like  the  sur- 
face of  very  acute  diffuse  eczema,  or  an  acute  balanitis;  there  is 
always  a  copious,  clear,  yellowish,  viscid  exudation;  the  sensations 
are  commonly  tingling,  itching,  and  burning,  i)Ut  the  general  health  is 
unaffected.  The  cancerous  growth  has  always  appeared  within  two 
years,  not  in  the  skin,  but  deeply  in  the  glands.  The  treatment  by 
ordinary  remedies  has  proved  unavailing;  removal  of  the  breast  is 
suofgestol  as  the  niuic  jiidltious  procedure. 

4.  Tumors  of  the  breast  ^  may  spring  from  the  epithelial  ele- 
ments of  the  gland,  or  from  its  connective  tissue ;  the  former  em- 
braces simple  hypertrophy,  adenoma,  soft  and  hard  cancer,  and  the 
latter  sarcoma,  fibroma,  and  myxoma.  ^lost  of  the  tumors  may  de- 
velop cysts  as  they  increase  in  size.  The  recognized  treatment  is 
removal,  and  the  success  of  the  operation,  as  well  as  the  extent  of 
the  incision,  must  depend  upon  the  nature  of  the  growth. 

(1.)  Non-malignant  tumors  of  the  breast  ^  more  often  occur  in  women 
under  forty;  tliey  are  covered  with  healthy  skin,  except  in  the  ulcerated  stage 
of  the  sarcomata,  and  the  skin  even  then  does  not  appear  infiltrated;  they  are 
somewhat  nodulated,  not  very  hard,  occasionally  partially  elastic,  movable,  and 
non-adherent;  the  nipple  is  rarely  retracted  and  the  superficial  veins  are  not 
markedly  dilated;  there  is  seldom  much  pain,  except  in  the  case  of  the  irritable 
tumor,  and  tlit-n  continuous  and  of  a  neuralgic  characier;  the  neighboring 
lymphatic  glands  are  not  involved;  there  is  no  tendency  to  multiplication  in 
internal  organs,  and,  therefore,  no  cachexia;  the  tumor  grows  slowly  and  rarely 
recurs  when  thoroughly  excised,  except  sarcomata,  which  grow  rapidly  and  are 
very  apt  to  recur. 

(2.)  Scirrhus3  is  seldom  met  with  in  persons  under  forty ;  it  originates  as  a 
small  nodule,  of  stony  hardness,  and  soon  becomes  fixed  and  adherent  to  sub- 
jacent tissues,  being  evidently  intiltrated  among  the  tissues  in  which  it  is  devel- 
oped; the  skin  becomes  widely  involved,  having  a  peculiar  pitted  or  dimpled 
appearance,  from  the  shortening  of  various  subcutaneous  fibres ;  in  an  extreme 
degree  the  pitting  gives  the  whole  breast  a  brawny  or  lardaceous  appearance  ; 
the  nipple  is  commonly  retracted  and  the  superficial  veins  dilated  ;  the  pain  is 
severe,  but  not  continuous,  of  a  lancinating  or  electric  character;  the  neigh- 
boring lymphatic  glands,  particularly  those  in  the  axilla  and  above  the  clavicle, 
become  involved  in   the  disease,  which  is  often  attended  by  a  marked  state  of 

1  Sir  J.  I'aget.  2  E.  Rindfleisch.  8  J.  Ashui-st,  Jr. 


588 


OPERATIVE  SURGERY 


cacliexia ;  the  tumor  usually  grows  prettj-  rapidly,  is  attended  with  ulceration, 
often  of  a  peculiar  character,  and  frequently  recurs  after  apparently  thorough 
removal. 

5.  Extirpation  of  the  breast,  in  part  or  whole,  is  undertaken  to 
remove  o-rowths.  If  the  tumor  is  non-malignant,  the  incision  should 
be  limited  to  the  growth,  and  care  be  taken  to  avoid  injuring  por- 
tions of  the  gland  not  involved  in  the  disease.  These  incisions  as- 
sume various  forms,  according  to  the  size  and  condition  of  the  tumor, 
but,  as  a  rule,  the  skin  should  not  be  sacrificed  unless  it  is  diseased. 
If  the  skin  is  involved,  the  incisions  should  be  so  directed  as  to  re- 
move the  affected  portion,  and  preserve,  in  good  condition,  the  other 
parts  of  the  breast i  (Figs.  606,  607). 


Fig.  606.  Fig.  607. 

Malignant  growths,  on  their  first  appearance  in  the  breast,  im- 
peratively demand  i-emoval,  for  experience  proves  that  life  may  thus 
be  prolonged,  a  certain  amount  of  immunity  from  bodily  suffering 
and  mental  distress  insured,  and  a  chance  of  freedom  from  all  local 
suffering  given. ^ 

The  operation  of  removing  the  tumor,  together  with  the  breast,  is  alwaj's  ad- 
niissiljle  when  the  health  of  the  patient  appears  to  be  favorable  to  recovery  from 
that  operation,  when  the  disease  involves  the  tissues  of  the  breast  only,  and 
when  the  axillary  lymphatic  glands  are  not  involved.-  It  may  also  be  under- 
taken with  advantage  when  the  disease  has  extended  to  the  skin  without  infil- 
trating the  cutaneous  tissue  to  a  wide  extent,  when  ulceration  has  taken  place, 
and  even  when  the  axillary  lymphatic  glands  are  distinctly  enlarged. -^ 

Removal  may  be  effected  by  incision  or  by  caustics.  Inv^'ision  is  to 
be  preferred  when  the  tumor  is  movable  and  ulceration  has  not  oc- 
curred. In  making  the  dissection  the  immediate  vicinity  of  the 
tumor  must  be  scrupulously  avoided.  The  shape  of  the  tuinor  must 
determine  the  incision,  but,  in  general,  it  should  be  in  the  direction 
of  a  line  radiating  from  the  nipple,  as  from  a  centre,  the  long  axis 
inclining  as  much  as  possible  downwards  and  outwards  when  the 
patient  is  recumbent.^  If  the  skin  is  involved,  two  incisions  will  be 
1  P.  C.  Delagarde.  2  j.  Birkett. 


THE   MAMMARY    Cf.AXDS.  589 

required  to  include  the  diseased  portion ;  the  lower  must  be  made 
first  to  avoid  the  flow  of  blood.  Operate  as  follows:  The  arm  of 
the  effected  side  beini;  elevated  to  render  tlie  pectoral  muscle  tense, 
make  the  first  incisions  through  the  skin  and  connective  tissue,  in 
the  form  of  an  ellipse,  or  circle;  separate  the  attachments  of  the 
tumor  from  its  connrctions  on  all  sides;  in  raising  the  tumor  from 
its  deep  connections,  commence  at  the  extremity  towards  the  axilla, 
expose  the  pectoral  muscle,  and  dissect  downwards  and  forwards 
towards  the  median  line  until  the  entire  mass  is  removed.  If  there 
are  enlarged  glands  towards  or  in  the  axilla,  extend  the  incision 
and  remove  them,  using  the  handle  of  the  scalpel  to  avoid  wound- 
ing vessels  or  nerves.  During  the  dissection,  control  the  haemorrhage 
by  pressure  with  dry  sponges  without  stopping  to  ligate  vessels. 
When  the  tumor  is  removed,  ligatures  or  torsion  should  be  applied 
to  all  bleeding  vessels  ;  the  surface  should  be  treated  with  carbolic 
solution,  or  zinci  chlorid.  ;  ^  then  the  margins  of  the  wound  should 
be  adjusted  with  sutures,  applied  at  every  quarter  inch,  commen- 
cing in  the  centre.  At  the  axillary  angle  an  opening  must  be  left 
for  drainage,  eiiher  by  horse-hair,  or  a  drain  tube.  The  external 
dressings  should  be  light  and  dry,  the  carbolized  gauze  or  jute  being 
preferable.  It  is  desirable,  in  applying  this  part  of  the  dressing, 
to  make  gentle  but  uniform  pressure  to  bring  the  deep  surfaces  of 
the  wound  in  accurate  apposition  with  a  view  to  immediate  union  ' 

The  value  of  caustics  in  the  treatment  of  cancer  of  the  breast  is 
very  great,  and  they  should  always  be  preferreil  to  the  knife  when 
ulceration  has  taken  place,  and  the  adhesions  are  deep  or  wide- 
spread. The  most  manageable  and  useful  application  is  the  anhy- 
drous sulphate  of  zinc  mixed  with  the  strong  sulphuric  acid  until  it 
forms  a  thick  paste.^  This  paste  should  be  freely  applied  repeatedly 
to  the  open  surface,  and  followed  by  poultices  and  carbolic  washes 
until  the  entire  mass  is  removed;  cicatrization  frequently  follows  the 
use  of  this  caustic.  Or,  caustic  arrows  may  be  ])repared  by  mixing 
a  concentrated  solution  of  chloride  of  zinc  with  flour  until  a  firm 
plaster  is  formed ;  this  mass  should  then  be  cut  into  arrow-shaped 
points;  they  are  inserted  by  first  thrusting  the  point  of  a  sharp  knife 
under  the  tumor  and  then  pushing  the  sharp  point  of  the  arrow  into 
the  wound  until  the  whole  mass  is  lodged  under  the  skin;  repeat  the 
insertion  at  intervals  of  an  inch  until  the  tumor  is  surrounded:  apply 
poultices  to  hasten  the  sloughing  and  separation  of  the  growth. 

1  C.  De  Morgan.  2  Sir  J.  Paget.  8  sjjr  j.  y.  Simpson. 


XL 

THE     EXTREMITIES. 

CHAPTER   LVIIL 

AMPUTATION. 

A\  amputation  is  required  to  preserve  life  from  the  consequences 
of  disease  or  injury,  and  is  justifiable  only  when  the  question  of  re- 
covery by  other  means  is  placed  beyond  all  reasonable  doubt,  or  the 
presence  of  an  incurable  disease  is  a  source  of  such  evil  or  discom- 
fort as  to  render  the  loss  of  the  limb  desirable  or  beneficial  to  the 
patient.^ 

No  operation  is  umlertaken  b}-  tlie  consciontious  surgeon  with  so  nuicii  reluc- 
tance and  real  pain,  and  with  such  a  profound  sense  of  personal  responsibility.'^ 
And  to  the  more  indifferent  operator  an  amputation  frequently  assumes  an  ex- 
treme importance  by  having  all  the  circumstances  attending  the  loss  of  a  limb 
criticallv,  and  often  savagely,  reviewed  in  the  courts. ^  These  responsibilities 
can  be  properlj'  met  only  by  the  most  deliberate  care  in  the  management  of 
ever\'  detail  in  each  case,  aided  b}'  the  best  available  counsel.  The  final  judg- 
ment as  to  the  necessity  of  an  amputation  in  anj-  given  case  must  be  sustained 
by  the  latest  surgical  experience,  for  an  amputation  that  would  formerly  have 
been  justified  would  now  be  repudiated  by  the  best  authority,  and  the  operator 
justlv  charged  with  ignorance  and  unskillfulness.^ 

1 .  The  time  of  the  operation  must  be  fixed  with  due  regard  to 
the  cause  which  necessitates  the  amputation,  and  the  condition  of 
the  patient.  There  is  a  time  when  interference  must  be  avoided, 
not  less  than  courted,  but  the  limits  of  the  two  periods  are  not  always 
well  defined,  and  must  be  left  to  the  judgment  of  the  surgeon  in  each 
individual  case.^  In  general,  it  may  be  advised,  (1)  when  injuries 
necessitate  immediate  amputations,  but  the  operation  should  be  per- 
formed during  the  period  of  reaction  from  shock,  or  between  the 
sixth  and  twenty-fourth  hour  after  the  accident;  (2)  If  the  disease 
is  acute,  avoid  the  period  of  active  intlammation,  rapidly-spreading 
gangrene,  and  acute  pyaemia;  (3)  In  chronic  affections  the  surgeon 
should  regulate  the  time  of  operation  according  to  the  principles  de- 
tailed. 
1  F.  C.  Skey.  2  s.  D.  Gross.  s  Elwell. 


AMPUTATION. 


591 


2.  The  place  of  amputation  must  l)e  (letermincd  with  n-ganl 
(1)  to  the  safe-ty  of  the  patient,  and  (2)  to  tlie  .«erviceablenes8  of  the 
resulting  limb;  the  former  nuist  be  settled  in  aeeordance  with  the 
teaehings  of  operative,  the  latter  of  nuchanieal  surt;ery.  Fortu- 
nately, experience  in  both  branches  of  surgical  art  is  now  in  liar- 
niony  in  tlie  selection  of  tin;  place  in  most  instances.  Two  principal 
divisions  of  amputations  have  been  recognized,  based  on  the  place  of 
operation,  namely,  (1)  in  the  continuity  of  shaft,  ("2)  in  the  contigu- 
ity or  articulation  of  bones. 

These  divisions  are  now  comparatively  uniniportaiit,  as  experience  proves 
that,  both  for  safety  to  the  patient '  and  serviceableness  of  .stump,  no  distinction 
should  be  made  between  amputation  in  the  continuity  and  conliguily,  with  the 
exception  of  the  ankle. -  In  the  upper  extremity,  all  the  conditions  unite  in 
favor  of  the  least  possible  sacrifice  of  part.s,3  for  t|,e  .safety  of  the  ]>atient  is  in 
proportion  to  the  distance  of  the  wound  from  the  lx>dy;  and  the  value  of  the 
stump,  in  prehension,  dppends  upon  the  number  of  articulations  preserved.  In 
the  lower  extremity,  the  same  rule  applies  to  tiie  wound,  but  as  the  stump  is  to 
be  used  in  locomotion,  it  ri'(|uires  breadth  ajid  lirniness  to  sustain  contact  with 
the  artificial  appliances  used  in  protjression,  and  hence  a  place  of  amputation 
must  be  selected  which  will  secure  these  conditions.  This  place  is  not  alwaj-s 
the  farthest  point  from  the  trunk  at  which  an  anipulation  could  be  performed  in 
a  given  case,  e.  y..  a  medio-tar^ial  amputation  and  stuni])  might  be  jiossible,  but 
the  stump  of  an  ankle-joint  amputation  would  be  much  more  serviceable.  But 
in  practice  it  is  not  diliicult  to  harmonize  the  two  indications;  when  the  ampu- 
tation nearer  the  trunk  would  give  the  better  stump,  the  danger  of  the  wound 
is  not  so  much  greater,  generally,  as  to  forbid  accepting  the  slightly  increased 
risk  for  the  life-long  advantage  gained. 

3.  The  preparations,  to  the  minutest  detail,  should  be  supervised 
by  the  operator.  Select  a  firjn  table,  about  three  feet  in  height,  and 
cover  with  two  or  three  folds  of  blanket; 
place  it  so  as  to  have  a  good  light  on  the 
stump  ;  provide  clean,  well-disinfected 
sponges,  towels,  slop-basins,  a  supply  of 
cold  water,  solution  of  carbolic  acid,  1  to 
20;  select  qualified  assistants,  namely,  one 
to  give  the  antcsthetic,  one  to  first  hold  the 
limb  and  thou  apply  ligatures;  one  to  use 
sponges,  one  to  attend  upon  the  instru- 
ments; place  the  patient  upon  the  table  and 
administer  the  anaesthetic;  aj)j)ly  the  elastic 
bandage  (Fig.  1),  or  the  tourniquet  (Fig. 
COS);  put  on  whatever  robe,  gown,  or  coat  ^'g.  608. 

is  deemed  necessary  for  j)roleetion;  take  a  position  upon  the  rio-ht 
side  of  the  limb,  grasping  it  with  the  left  hand,  above  the  point  fixed 
for  the  operation,  and  with  the  right  hand  take  the  knife  selected, 

1  Legouest.  ^  E.  D.  Hudson.  a  T.  Bryant. 


592 


OPERATIVE  SURGERY. 


catlinn 


Fig.  009. 


and  liokl  it  in  the  position  adapted  to  give  the  freest  play  of  the 
blade  in  executing  the  jiarticiilar  method  decided  upon. 

In  the  api)lifation  of  the  tourniquet  to  the  thigli,  fiv.<t  place  the  cylinder  of 
the  roller  under  the  strap  (Fig. 
608),  so  that  it  will  be  tirmly 
maintained,  and  theji  place  the 
cylinder  ovtr  the  artery  ( Fig.  609), 
fasten  the  strap,  and  turn  the 
screw. 

4.  The  instruments  which 
are  specially  reipiired  to  form 
a  complete  amputating  case, 
are  a  long   and   short  knife, 
,  metacarpal  saw,  scalpel,  ten- 
aculum, saw,  bone  forceps,  artery  for- 
ceps, needles,  tourniquet,  and  elastic 
bandage.^ 

The  knife,  a  (Fig.  610),  selected  for  each 
operation,  should  be  of  about  twice  the 
length  of  the  diameter  of  the  limb;  the  cat- 
ling, b,  is  a  doui)le-edged  knife,  the  two  edges  being  parallel 
until  they  converge  to  form  tiie  point;  the  scalpel,  c,  is  large 
and  strong,  having  a  firm  handle. 

The  remaining  instruments  are  those  in  common 
use. 

The  best  atomizer  (Fig.  611)  gives  a  large  volume 
of  fine  spray  which  becomes  a  light  fog  around  the 
operator  and  his  assistants. ^  The  coarse  spr,av  which  Fig.  610. 
atomizers  generally  deliver  is  not  only  very  inconvenient  to  the 
operator  by  drenching  and  benumbing  his  hands,  but  it  is  far  less 
effective  as  a  disinfectant.  The  antiseptic  gauze  should  be  used,  if 
obtainable. 

An  apparatus  which  effectually  meets  the  indications  of  giving  a  spray  as  fine 
as  the  lightest  fog,  and  continuing  for  a  sufRciently  long  period  without  interrup- 
tion or  accident,  is  the  following. 2  It  consists  (Fig.  611)  of  a  copjier  tubular 
boiler,  finnly  attached  to  the  frame  of  a  spirit  lamp,  and  is  provided  with  deli- 
cately constructed  tubes  for  the  atoniization.  by  high  steam  ])ressure,  of  the  anti- 
septic solution.  Tlie  lamp  is  balanced  on  a  long  central  pivot,  which  is  tirmly 
coiniected  with  a  transverse  bar.  By  this  arrangement  the  lamp  acconnnodates 
itself  to  all  motions  and  preserves  the  same  level,  thereby  preventing  spilling 
of  alcohol.  The  whole  instrument,  when  comiected,  measures  eleven  inches 
in  height,  and  seven  inches  in  diameter.  The  several  parts  are  as  follows:  — 
A,  the  tubular  boiler  which  is  filled  with  water  and  where  steam  is  generated; 
the  openings  of  tubes  or  flues  are  displayed  on  the  upper  surface;  these  tubes, 
four  in  number,  increase  the  heating  surface  of  the  boiler  and  carry  off  the  sur- 


1  F.  Esmarch. 


"-  L.  A.  Sass 


AMPrTATWy. 


59;3 


plus  heat  which  would  be  reflected  on  the  alcohol  lamp  beneath;  B,  is  a  safety 
valve  ami  lid  for  relief  of  boiler;  C,  an  ivory  button  for  raisinj^  the  boiler  from 
the  frame  of  the  spirit  lamp;  D,  ivory  handle  for  rotating  the  lid  and  fafvty  valve 
to  permit  the  tillinf(  of  the  boiler;  A",  ivory  screw  for  securely  (ixint;  the  lid; 
/'  i.s  a  steam  tube  and  couplinj;;,  made  of  brass  ;  G,  sprav  tubes  made  of  silver 
with  a  liniiifi;  of  platina,  so  that  other  than  carboli/.ed  solutions  can  be  used 
without  chemical  decomposition  ;  //.  ivory  hanille  for  roiatiuj;  sprav  tubes  up- 
ward or  downward  as   far  as  required  ;   /,  ivory  screw  for  lixinj;  sjiray  tubes 


and  regulatinj;  the  volume 
ber  tubes  connected  with 
medicated  fluid;  K,  glass 
bars)  for  showing  height 
band  firmly  attached  to 
perpendicular  bars,  serves 
holds  the  boiler  in  posi- 
connecting  base  and  metal 
the  spirit  lamp;  C  is  the 
for  filling  lamp;  Q,  fen- 
in  lamp;  R,  rachet  screw 


and  force  of  the  s[)ray;  J,  rub- 
spray  tubes  and  dipping  into 
water  gauge  (with  protecting 
of  water  in  boiler  ;  L,  metal 
frame  of  spirit  lamp  by  four 
as  a  flame  protector  and  securely 
tion  ;  M.  perpendicular  bars 
band  ;  .V,  base  of  the  frame  of 
alcohol  lamp;  /",  metal  funnel 
estra,  showing  height  of  alcohol 
for  regulating  wick  and  flame; 


S.  movable  stage  for  sup- 
porting glass  receiver;  T, 
glass  receiver  for  contain- 
ing medicated  solution  ; 
U,  wooden  handle  for  hold- 
ing apparatus. 

By  rotating  the  ivory 
handle  D,  the  boiler  can 
be  supplied  with  hot  water 
until  the  liquid  reaches 
the  top  of  the  glass  gauge 
K ;    the   lamp,   0,  is  now 

lighted  and  in  a  few  minutes  sufficient  steam  is  generated  for  the  development 
of  the  spray.  A  steady  uniform  and  continuous  spra\'  issues  from  each  spray 
tube  G,  G,  its  force  and  volume  being  regulated  by  the  ivory  screw  /.  and  the 
direction  fixed  by  the  ivory  handles  //,  //.  The  instrument,  now  in  full  opera- 
tion, and  mounted  on  an  adjustable  stand,  requires  no  further  attention,  except, 
in  protracted  operations,  to  re|)lenish  the  spirit  lamp  and  glass  receiver  holding 
the  solution,  a  matter  easily  accon\plished  and  causing  no  interruption.  The 
spray  thus  produced  can  be  thrown  a  distance  of  five  or  six  feet,  and  can  be 
38 


Fig.  Oil. 


">94  OPERATIVE  SURGERY. 

kept  in  continuous  action  for  nearly  four  hours  without  replenishing  boiler  ot 
lamp. 

If  the  steam  atomizer  is  not  at  hand,  use  the  hand  atomizer,  and  if  this  is  not 
convenient,  thoroughly  disinfect  every  part  of  the  wound  with  a  solution  1  to 
20.  The  spray  is  by  no  means  necessary  for  the  thorough  disinfection  of  fresh 
wounds,  and  the  good  results  may  be  obtained  by  api)lying  tiie  antiseptic  to 
every  part  of  the  open  wound,  and  follow  it  with  carbolized  dressings. 

5.  The  method  of  operation  should  aim  to  secure  a  well-nour- 
ished covering  of  the  stump,  neither  scanty  nor  redundant,  and  freely 
movable  cicatricial  tissue.  To  obtain  such  results,  (1)  the  soft  parts 
must  be  very  nicely  adapted  to  the  surface  to  be  covered,  and  well- 
suf)plied  with  blood-vessels  ;  (2)  the  cut  surface  of  bone  must  be 
immediately  covered  by  the  periosteum,^  or  the  deep  fascia  of  the 
part,  in  order  to  prevent  the  superficial  fascia  and  integument  from 
becoming  too  firmly  attached  to  the  cicatricial  tissue  of  the  end  of  the 
bone.  These  results  are  secured  by  raising  the  periosteum  with  the 
soft  tissues  and  applying  it  to  the  cut  end  of  the  bone. 

Tlie  objection  to  the  periosteal  covering  of  the  bone  that  osteophytes  are  liable 
to  form  on  the  extremity,^  and  render  the  stump  tender,  are  trivial  when  com- 
pared with  the  advantages  which  follow  the  protection  which  it  affords  from 
necrosis  and  osteo-myelitis,  and  the  basis  which  it  forms  for  a  movable  cover- 
ing. If  osteophytes  become  troublesome,  thex'  may  readily  be  removed  by  a 
slight  operation. 

No  one  method  can  be  adapted  to  every  part  and  all  the  condi- 
tions under  which  amputations  are  performed,  and  hence  great  dis- 
cretion is  always  required  in  selecting  that  method  in  any  given 
case  which  will  fully  meet  all  indications.  It  also  frequently  happens 
that  the  mutilation  of  parts  is  so  great  that  the  surgeon  can  form  the 
coverings  of  the  stump  by  no  fixed  rules,  but  must  exercise  his  inge- 
nuity in  patch-work.  But  if  the  conditions  essential  to  a  sound  and 
useful  stump  are  constantly  kept  in  view,  any  of  the  stereotyped  or 
extemporized  methods  may  be  made.  Avith  patience  and  dexterity,  to 
yield  the  most  gratifying  results.  The  recognized  methods  of  ampu- 
tation are  (1)  the  circular;  (2)  the  single  flap;  (3)  the  double  fiap ; 
(4)  the  rcciangular;  (5)  the  bilateral  flap;   (6)  the  periosteal  flap. 

(1.)  The  circalar  operation  can  be  executed  more  quickly  by  the  following 
than  by  the  ordinary  method  (Fig.  617):  .Stand  upon  the  right  side  of  the  limb,  the 
left  foot  thrown  forward  and  placed  lirmly  upon  the  floor,  the  right  knee  bend- 
ing sutticiently  to  give  freedom  of  motion  to  the  body;  grasp  the  limb  above 
the  point  of  operation  with  the  left  hand,  and  take  the  handle  of  the  knife 
between  the  thumb  and  fore  and  second  fingers  of  the  right  hand,  lightly 
supporteil  by  the  other  fingers;  stooping  surticiently  to  allow  the  right  arm  to 
encircle  the  limb  readily,  carry  the  knife  around  until  the  blade  is  nearly  per- 
pendicular to  the  long  axis  of  the  limb  on  the  side  next  to  you  with  the  point 
downwards,  and  the  hand  above  the  limb,  1  (Fig-  612). t      Connneuce    the   cut 

1  McGill.  2  L.  Oilier. 


AMPUTATION. 


595 


with  the  heel  of  the  knife,  giving  slightly  sawing  motions,  and  bring  the  hand 
under  the  limb.  2,  and  then  directly  upwards  upon  the  side  next  to  you,  3,  until 
the  heel  touches  the  point  of 
commencement,  4;  the  han- 
dle of  the  knife  held  thus 
delicately   will   change    its 
relative  positions  as  it  passes 
around  the  limb  without  the 
slightest  enibarrassment  to 
the  operator;  if  the  handle 
is  firmly  grasped  (Fig.  617) 
in   the   hand,    the    incision 
cannot  l)e  completed  with- 
out the  aid  of  the 
other  hand,  or  an 
awkward     move- 
ment of  the  hand 
holdingthe  knife; 
the    ease   with 
which  the  incision 
is  completed  will 
depend  much  up- 
on    whether      it 
commences    well 
down    upon    the 
side  of  the  limb 
next  to  the  opera- 
tor; raise  the  skin  from 
the  first  layer  of  mus- 
cles by  dissection,  and 
turn  it  upwards,  two  or 
three  inches,  according 
to  the  diameter  of  the 
limb,  like  the  cuff  of  a 
coat.     (2.)  Divide  the 

first  layer  of  muscles  at  the  margin  of  the  retracted  integument  by  the  circular 
(Fig.  G12)  incision,  as  of  the  skin  :  raise  this 
hiyer  with  the  knife  and  draw  it  still  further 
upwards;  divide  the  last  layer  of  muscles 
down  to  the  bone  (Fig.  fil3)  by  the  same 
sweep  of  the  knife  as  before  given.  (2.)  Saw 
the  bone  at  the  apex  of  the  cone. 

(2.)  The  single  flap,  or  a  short  anterior  and 
long  posterior  flap,  is  performed  as  follows: 
The  patitMit  being  placed  in  the  proper  posi- 
tion, the  operator,  standing  upon  the  right  side 
of  the  limb,  grasps  the  thigh  with  the  left  hand, 
placing  the  fingers  and  thumb  upon  opposite 
points;  he  then  applies  the  heel  of  a  long  am- 
putating knife  on  the  further  side  of  the  limb 
at  the  ends  of  fingers,  and  drawing  it  in  a 
semicircular  direction  over  the  limb  to  the  end 
of  the  thumb,  with  this  single  sweep  divides 


Fig.  G12. 


Fio.  613. 


596 


OPERATIVE  SURGERY. 


all  the  soft  parts  down  to  the  bone;  without  entirely  removing  the  knife  it  is 
withdrawn  sufficiently  to  enter  the  point  at  the  angle  of  the  wound,  and  is 
made  to  translix  the  limb,  passing  under  the  bone,  and  emerging  at  tiie  angle 
of  the  wound  on  the  opposite  side;  a  flap  is  then  cut  of  the  requisite  length 
from  the  posterior  part  of  the  thigh;  the  flaps  are  retracted,  the  knife  carried 
around  the  bone,  and  the  saw  applied  at  the  highest  part  of  the  wound. 

(3.)  Double  flaps  are  formed  as  follows:  The  patierit  being  properly  arranged, 
the  operator,  syjiuling  upon  the  side  of  the  limb,  grasps  the   soft   parts  and 

brings  them  forward;  he 
then  transfixes  the  limb, 
the  knife  grazing  the  up- 
per surface  of  the  bone, 
and  makes  an  anterior  flap 
(Fig.  614);  the  knife  is  re- 
introduced, and  passing  un- 
der the  bone  a  posterior  flap 
is  made  longer  than  the  an- 
terior (Fig.  614),  to  com- 
pensate for  the  greater  re- 
traction ;  the  operation  is 
completed  as  in  the  former 
method.  1  Flaps  may  also 
be  made  from  the  sides  of 
the  limb;  the  knife  is  in- 
troduced in  the  centre  of  the  limb,  directly  down  to  the  bone,  on  one  side  of  which 
it  is  passed  to  the  opposite  side  of  the  limb,  and  a  flap  is  then  formed  (Fig. 
123);  the  knife  is  then  introduced  and  a  flap  made  from  the  opposite  side;  the 
flaps  are  strongly  retracted,  and  the  bone  sawed. 

(4.)  The  rectangular  flaps 2  are  made  as  follows:  The  operator  makes  a 
longitudinal  incij^ion  on  either  side  of  the  limb  (Fig.  615),  in  length  equal  to 
two  thirds  of  the  circumference  of  the  limb  at  tliis  part;  a  second  incision,  ex- 
tending to  the  bone,  unites  the  lower  extremities  of  these  two  incisions;  this 
quadrilateral  flap  is  raised  from  the  bone  ;  a  thiid  incision  made  transversely 


Fig.  614. 


Fig.  615. 


Fig.  616. 


down  to  the  bone,  forms  the  posterior  flap;  both  flaps  are  raised  and  firmly  re- 
tracted (Fig.  616),  the  bone  sawn  at  its  point  in  the  flaps,  and  the  flaps  united. 
(5.)  The  bilateral  flaps  include  only  the  skin,  or  may  involve  all  of  the  soft 


1  Sir  W.  Fergussoii. 


2  Teale. 


AMPUTA  riON. 


597 


parts  ilown   to   tlie  bone. 


The  former  consists  of  double  flaps  of  the  integu- 
ments and  circular  incision  of  the 
muscles;  1  the  flaps  should  be  suf- 
ficient to  meet  without  effort, 
siiould  correspond  in  size,  and  not 
be  made  too  arched;  in  dividing 
the  muscles,  the  knife,  unless  the 
limb  be  of  unusual  dimensions, 
should  be  carried  down  to  the  bone 
at  once,  and  this  can  only  be  done 
by  the  application  of  considerable 
force,  great  care  being  taken  that 
the  muscular  mass  behind  the  bone 
be  not  pushed  before  the  knife,  but 
divided  without  displacement  from 
its  natural  relations  to  the  parts 
around.  When  the  limb  is  very 
large,  it  would  be  well  to  divide 
the  superficial  muscles  first  and 
allow  them  to  retract,  before  the 
Fig.  617.  division  of  the  remainder. 

(6.)  The  periosteal  flap  is  most  perfect  when  it  is  raised  with  the  other  flap; 
to  effect  this  readily  tiie   incision  in  any  form  of 
operation  may  be  directly  down  to  the  bone;  if  the 
bone  is  then    di- 
vided,   an   assist- 
ant    m  a  y   grasp 
the   e  X  tr  e  m  i  ty 
with  stout  forceps 

while  the  operator  raises  the  periosteum,  beginning 
at  the  extremity  of  llie  cut  bone;  the  periosteotome 
may  be  used,  but  in  general  the  thumb  nails  will 
be  found  most  eflicient.  The  periosteum,  thus 
raised,  covers  the  central  part  of  the  flap  (Fig.  G18;^ 
and  when  the  flap  is  brought  over  the  e.xtremity,  the  periosteum  niakes  a  perfect 
covering,  while  the  tissues  between  the  skin  and  periosteum,  being  uninjured, 
rapidly  unite. 

6.  The  bone  must  be  carefully  divided  a.«i  follows  :  The  jierio.'steum 
having  been  eut  completely  around  the  bone,  as  \\v^\\  up  in  tlie  Hap  as 
possible,  employ  the  saw  as  does  the  cabinet-maker,  —  first  apply  the 
heel,  and  draw  the  saw  slowly  but  firmly  acro.ss  the  bone  to  make  a 
groove,  and  then  move  it  with  as  much  rapidity  as  the  operator  may 
choose,  until  the  bone  is  nearly  divided,  when  it  is  to  be  moved  more 
slowly  to  avoid  splintering  the  last  connections ;  with  the  bone  for- 
ceps clip  off  any  sharp  or  [jrojecting  edges,  and  bevel  the  end  of  the 
bone  smoothly.  Where  there  is  a  single  bone  it  will  be  found  easier 
to  apply  the  saw  nearly  perpendicularly  on  the  side  ojjpo-ite  to  tlie 
operator ;  where  there  are  two  bones  the  saw  should  be  (iist  and  last 
applied  to  tlie  largir  and  firmer  bone,  the  smaller  bone  being  com- 
pletely divided  while  the  saw  is  engaged  in  the  larger  bone. 
1  F.  C.  Skev. 


Fig.  618. 


598 


OPERATIVE  SURGERY. 


7.  The  wound  must  first  be  protected  from  hgemorrhage  hy  liga- 
tion and  torsion  of  vessels;  much  valuable  time  is  saved  by  seizing 
all  the  bleeding  vessels  at  once  with  suitable  forceps  (Fig.  619),  and 
ligating  each  one  in  turn  ; 
every  point  where  there  is 
any  evidence  of  haemorrhage 
must  be  examined,  and  the 
vessel  twisted  or  tied.  The 
wound  must  be  closed,  dressed, 
and  treated  according  to  the 
principles  already  given.  This 
object  may  be  accomplished 
(1)  by  closing  the  wound  with 
so  large  a  number  of  wire  su- 
tures that  supporting  adhesive 
strips  will  not  be  required ; 
by  inserting  a  proper  drain- 
age tube  so  as  to  relieve  the 
wound  of  all  accumulating 
fluids  ;  (3)  by  supporting  the 
parts  in  such  manner  by 
splints,  or  slings,  or  pads,  that 
it  need  not  be  moved  in  dress- 
ing; (4)  the  application  of  Fig.  619. 
such  dressings  as  support  and  protect  the  wound,  but  admit  of  easy 
change. 

The  most  important  features  in  all  methods  now  recognized  are  perfect  clean- 
liness, and  absolute  rest,  or  freedom  from  all  sources  of  irritation  and  excite- 
ment. Valuable  as  is  the  antiseptic  method,  carried  out  in  all  its  details,  most 
excellent  results  may  be  obtained  in  treating  wounds  by  first  cleansing  the  sur- 
face with  carbolic  acid  solution,  and  then  supporting  the  part  so  that  the  dress- 
ings nia3'  be  changed  without  disturbing  the  wound;  i  or,  by  leaving  the 
wound  open  and  applying  bals.  Peru  freely  while  the  drainage  is  free.2  Or,  the 
wound  may  be  kept  entirely  dry  except  tlie  natural  drainage,  by  the  dressings; 
after  the  application  of  wire  sutures,  apply  oakum,  or  cotton  wool, 3  with  splints. 
The  re-dressing  of  these  wounds  is  avoided  as  long  as  possible,  the  pulse  and 
temperature  being  the  guide  as  to  the  existence  of  septic  matter.* 


AMPUTATIONS  IN  THE  UPPER  EXTREMITY. 

Operative  and  mechanical  surgery  unite  in  enforcing  the  rule  that 
in  the  hand  —  and  the  same  is  true  of  the  whole  upper  extremity  — 
no  part  should  be  removed  that  can  be  saved  ;^  no  instrument-maker 
can  contrive  anything  half  so  good  as  even  one  finger.  ® 

1  G.  W.  Callender.  2  j.  r.  Wood.  3  a.  Guerin.  *  S.  Gamgee. 

6  C.  J.  Guthrie.  «  R.  Listoi.. 


AMPUTATION. 


599 


1.  The  phalanges  arc  ofu-n  injured  in  such  a  manner  as  to  com- 
pel the  surj^con  to  perform  a  circuhir  (l.ip,  or  some  moflilied  opera- 
tion to  secure  the  requisite  coverini^.  l>ut  when  the  parts  will  ad- 
mit, the  sin'^le  i)ahnar  flap  is  [)referal)le  in  all  am])Ufations  of  the 
fingers,  as  the  cicatrix  is  by  this  method  removed  to  the  dorsal  sur- 
face, the  stump  is  firm  and  well  adapted  for  use,  and  the  tactile  sen- 
sation is  less  impaired. 


Fig.  620. 


G21. 


The  first  plialanx,  b  (Fit;.  020),  articulates  with  the  metacarpal  bone,  a,  al>ove, 
and  with  the  sucoiul  plialanx  bylow;  the  six-ond  |>halanx,  (/(Fig.  C20),  articu- 
lates with  the  lirst  and  third  phalaufies;  the 
third  phalanx  articulates  above  with  the  sec- 
ond, and  below  presents  the  free  extremity 
of  the  finger.  The  anatoniic.il  guides  to  tlie 
articulations  are  the  osseous  prominences, 
c  (Fig.  620),  and  the  transverse  depressions, 
c(Fig  621),  in  the  skin  on  the  palmar  sur- 
face. Uetween  the  bony  projections  at  the 
side  of  the  finger,  at  the  articulation  of  the 
second  and  third  phalanges,  a  depression 
marks  the  position  of  the  articulation;  a 
prominence  is  readily  detected  on  the  dor- 
sum of  the  second  phalanx  just  in  front  of  its 
articulation  with  the  distal  extremity  of  the 
first  phalan.x;  the  articulation  of  the  lirst 
phalan.K  with  the  metacarpal  bone,  is  immediately  behind  the  bony  prominences 
of  the  proximal  extremity  of  the  lirst  phalanx.  The  transverse  depressions  in 
the  skill,  on  the  palmar  surface  of  each  finger,  are  three  in  number,  and  have 
the  following  relation  to  tlie  corresponding  articulations,  commencing  with  the 
extremities  of  the  lingers,  held  in  an  extended  position:  The  lirst  depression  is 
situated  about  a  line  and  a   6  t, 

half  above  the  articulation, 
/  (Fig.  621),  between  the 
third  and  second  phalanges; 
the  second  depression  is  sit- 
/A\  {  )1  1  "'''^''1  exactly  over  the  ar- 
(It\\  If  I  ticulation,  rf  (Fig.  621),  be- 
IK^^_--Y^j/  tween  the  second  and  lirst 
^^*''^"*  '  phalanges  ;  tlie  third  de- 
pression, c  (Fig.  621),  situ- 
ated at  the  commissure  of 
the  fingers,  is  about  an  inch  below  the  ar- 
ticulation, />  (Fig  621),  of  the  tirst  phalanx  , 
with  the  metacarpal  bone.  When  the  liii-  g 
ger  is  placed  in  a  state  of  extreme  flexion, 
it  will  he  seen  (Fig.  622),  that  the  relations 
of  the  articulation  change,  and  hence  the  point  at  wliich  the  articulation  is  to  be 
sought  will  depend  on  the  position  of  the  finger.  The  articulations  of  the  plia- 
/aiigcs  with  each  other  are  all  ginglymoid;  the  distal  extremities  of  the  lirst  and 
second  phalanges,  a  a  (Fig.  62-'}),  are  smaller  than  the  proximal,  bb  (Fig.  62.1), 
and  terminate  on  each  side  in  two  lateral  condyles,  having  a  slight  concave  ar- 


FiG.  622. 


Vui.  62.'}. 


600 


OPERA  TI VE  S  UR  GER  Y. 


ticular  surface  between  them,  which  is  prolonged  on  the  palmar  surface;  the 
proximal  extremities  of  the  second  and  third  phalanges  present  a  corresponding 
prominence  in  the  centre  of  their  articulating  surface,  dividing  it  into  two  con- 
cave surfaces,  and  tlius  making  a  ginglj-moid  joint.  They  have  strong  lateral 
f>  ligaments  and  are  in  relation,  on  their  pal- 

j  .  (ij\  \     I  qa       niar  aspect,  with  the  tendons  of  the  flexor 

muscles.  The  articulations  of  the  first  pha- 
langes, b  h  (Fig.  G24),  with  the  metacarpal 
bones,  n  a  (Fig.  624r),  are  enartlirodial ;  the 
phalanx  alone  is  movable,  and  when  flexed 


Fig.  624. 


Fig.  625. 


at  a  right  angle  is  carried  below  the  extremitj'  of  the  metacarpal  bone,  the  ar- 
ticular surface  of  the  latter  alone  presenting. 

In  amputation  through  the  shaft,  hold  the  condemned  finger  be- 
tween the  thumb  and  index  finger  of  the  left  hand  (Fig.  625),  flex 
the  hand  upon  the  forearm  to  place  the  other  fingers  so  far  posterior 
as  not  to  be  touched  by  the  bistoury;  if  the  flap  will  not  be  sufliciently 
rounded,  bring  forward  the  heel  of  the  knife,  and  cut  the  flap 
rounded  on  the  side  of  the  finger  nearest  the  right  hand  ;  ^  make  a 
second  incision  on  the  dorsum  uniting  the  base  of  the  palmar  flap, 
and  divide  the  bone  with  a  fine  saw  or  cutting  forceps. 

In  disarticulation  of  the  last  phalanx,  pronate  the  hand,  and  re- 
quire an  assistant  to  hold  apart  the  sound  fingers;  seize  the  phalanx 
with  the  thumb  and  index  finger,  and  bend  it  to  an  angle  of  forty- 
five  degrees;  recognize  the  line  of  the  joint  as  follows:  on  the  dorsal 
surface  there  is  a  well-marked  fold  in  the  skin,  and  the  joint  is  half 
a  line  below  it;  or,  if  this  is  not  found,  recognize  the  dorsal  projec- 
tion formed  by  flexion,  and  cut  half  a  line  beyond  it;  or,  seek  the 
termination  of  the  palmar  fold,  and  find  the  joint  half  a  line  below 
it;  take  a  straight  bistoury,  and  applying  its  heel  perpendicularly 
on  the  recognized  extremity  of  the  interarticular  line,  cut  from  left 
to  right  a  veiy  small  semi-circular  dorsal  flap,  and  terminate  it  at 
iis  other  extremity,  dividing  the  capsular  ligament;  without  enter- 
ing the  joint,  cut  the  lateral  ligaments  thus:  for  the  one  situated  to 
the  left,  carry  the  bistoury  on   tlie  side  perpendicularly  to  the  axis 

1  A.  Guerin. 


AMPUTATION. 


601 


of  the  last  phalanx,  the  handle  nearer  the  operator  than  the  point, 
and  the  edge  al:^o  slightly  turned  toward  the  operator;  this  incision 
is  perfeetly  suited  to  the  artieular  surfaees,  and  tlie  ligament  is  di- 
vided at  the  first  cut;  eut  the  second  lateral  ligament  in  the  same 
manner,  tlie  handle  of  the  histoury  being  turned  downwards,  and 
away  from  the  operator. 

These  tiiree  steps  may  be  comprised  in  one,  and  the  skin,  tlie  dorsal  and  lat- 
eral ligaments  divided  at  once.  When  the  distal  phalanx  alone  is  involved,  as 
in  caries  or  necrosis,  the  nail  and  soft  parts  should,  if  possible,  be  preserved; 
it  is  nearly  always  feasible,  and,  if  the  periosteum  has  not  been  destroyed,  it 
is  not  unfrequently  followed  by  reproduction  of  the  phalanx,  though  rarely  in 
a  perfect  manner. "^  Bring  the  palmar  flap  into  position,  secure  it  by  a  narrow 
bandage  laid  over  the  stump  in  the  direction  of  the  long  axis  of  the  linger,  then 
make  fast  by  a  few  turns  of  the  roller.-  To  disarticulate  the  second  phalanx 
the  proceeding  is  the  same,  only  the  dorsal  incision  should  start  on  each  side 
on  a  level  with  the  palmar  fold  in  the  skin.^ 

2.  The  entire  fiuger  may  be  removed  at  the  metacarpo-phalangeal 
articulation. 

The  joint  is  located  an  inch  above  the  commissure,  or  it  may  be  recognized 
by  making  strong  traction  on  the  finger  and  thus  separating  the  joint. 

Grasp  the  finger  in  a  prone  position  on  its  palmar  and  dorsal  sur- 
faces by  the  fingers  and  thumb  of  the  left  hand,  and  fle.x  to  an  angle 
deb  of  forty-five  degrees;  commence  an  in- 

cision on  the  dorsal  aspect  of  the  joint 
a  quarter  of  an  inch  above  at  a  (Fig. 
62G),  and  carry  it  down  to  the  com- 
missure, c,  then  across  the  palmar  sur- 
face to  the  opposite  side.  b.  in  the  fold 
of  the  skin,  the  finger  being  forcibly 
extended;  thence,  the  finger  being  again 
flexed,  the  incision  is  continued  up- 
wards to  a;  dissect  the  borders  of  the 
wound  from  the  head  of  the  phalanx, 
enter  the  joint  on  its  dorsal  aspect,  di- 
viile  the  extensor  tendons  an<l  lateral 
ligaments,  increase  the  flexion  with  an 
effort  to  luxate  the  joint  which  renders 
the  flexor  tendons  ea.'^y  of  division.  To  give  greater  ."vnimetry  to 
the  hand,  the  head  of  the  metacarpal  bone  may  also  be  removed. 
Or,  double  flaps  may  be  made,  a,  b,  c  (Fig.  G26). 

3.  The  four  fingers  may  be  removeil  at  a  single  operation. 

The  distal  extremities  of  the  metacarpal  bones  are  not  all  on  the  same  line; 
those  of  the  index  and  ring  are  nearly  on  a  level,  while  that  of  the  miildle  fin- 
ger is  about  half  aline  lower,  and  that  of  the  little  finger  is  a  half  a  line  higher. 
1  S.  D.  Gross.  2  F.  H.  Hamilton.  8  Lisfranc. 


Fig.  626. 


602 


OPERATIVE  SURGERY. 


The  hand  being  well  pronated,  grasp  the  foui-  fingers  with  the  left 
hand  and  flex  them  moderately  while  an  assistant  supports  the  hand 

and  retracts  the  skin  as 
much  as  possible;  with  a 
straight,  narrow  knife, 
make  a  curved  dorsal  in- 
cision, a,  b,  c  (Fig.  627) 
with  its  convexity  looking 
downwards,  from  six  to 
eight  lines  below  the 
heads  of  the  metacarpal 
bones,  from  the  index  to- 
wards the  little  finger,  if 
the  left  hand,  and  in  the 
opposite  direction,  if  the 
right;  the  extensor  ten- 
FiG.  627.  dons  being  exposed  by  the 

retraction  of  the  integuments,  which  is  assisted  liy  a  few  strokes  of 
the  knife,  open  each  of  the  metacarpo-[)halangeal  articulations;  di- 
vide the  extensor  tendon  first,  then  the  lateral,  and  finally  the  palmar 
ligamentous  attachments;  carry  the  knife  through  the  articulations  to 
the  palmar  aspect  of  the  phalanges,  and  cut  out  a  flap,  which  is 
limited  anteriorly  by  the  folds  in  the  skin  at  the  base  of  the  fingers 
on  their  palmar  surfaces. 

By  the  same  method,  two  or  three  fingers  may  be  amputntert,  the  sound  fin- 
gers being  held  aside;  the  dorsal  flap  is  then  formed  by  tlie  point  of  the  knife; 
or  the  hand  may  be  iield  in  tlie  supine  position  and  the  flap  made  first  from  the 
paUiiar  surface.!  The  appearance  of  the  stump  is  improved  by  sloping  the  pro- 
jecting portion  of  eacli  i<nuckle  with  cutting  pliers."^ 

4.  The  thumb  may  be  amputated  at  its  phalangeal  or  metacarpal 
articulation.  The  first  is  performed  in  the  same  manner  as  that  of 
the  fingers,  but  the  removal  at  the  metacarpo-phalangeal  articulation 
requires  large  flaps,  owing  to  the  great  size  of  the  head  of  the  meta- 
carpal bone.  Make  an  incision  on  the  dorsal  aspect,  convex  up- 
wards, the  centre  being  a  little  above  the  Joint,  and  the  extremities 
terminating  on  each  side  at  the  end  of  the  palmar  transverse  fold, 
extend  the  thumb  and  make  a  palmar  convex  incision,  uniting  the 
extremities  of  the  first,  the  centre  extending  midway  between  the 
transverse  cutaneous  fold  alluded  to  and  that  marking  the  articula- 
tion of  the  first  and  second  phalanges;  open  the  joint  and  complete 
the  disarticulation,  removing  the  sesamoid  bones.  The  palmar  flap, 
applied  to  the  end  of  the  bone,  should  accurately  fit  the  curved  in- 
cision above. 

1  Lisfranc.  -  S.  D.  Gross. 


AMPUTATION. 


603 


Fu;.  023. 


5.  A  single  metacarpal  bone  is  removed  by  an  incision  on  the- 
dorsal  aspect,  corresponding  in  length  with  the  portion  of  the  lx>ne 
to  be  removed.  Sej)arate  the  soft  parts  cautiously  from  the  bone, 
the  knife  being  carried  parallel  with  its  long  axis  to  avoid  woun<l- 
ing  the  palmar  arch;  having  made  the  incisions  on  both  sides,  pass 
the  point  of  the  knife  under  the  bone,  so  as  to  api)ear  at  the  ojjpo- 
site  side,  and  then,  hy  carrying  it  forwards  in  contact  with  the  under 
surface  of  the  bone,  divide  the  soft  parts  at  one  section;  if  the  opera- 
tion is  of  cither  the  third  or  fourth 
metacarpal  bone,  the  section  should 
be  made  with  the  i)one  forceps;  if  of 
the  metacarpal  bone  of  the  thumb,  saw 
it  perpendicularly  to  its  axis;  if  of  the 
index  finger,  make  a  section  obliquely 
from  without  inwards,  the  hand  bein^ 
supine;  if  of  the  little  finger,  from 
within  outwards  (Fig.  628)  a,  the  soft 
parts  being  withdrawn  by  the  retract- 
or, h. 

6.'  Amputation  of  the  four  meta- 
carpal bones  (Fig.  629)  is  made  as 
follows:  Make  a  palmar  flaj)  as  in  dis- 
articulation of  all  the  fingers  and  a  similar  incision  on  the  dorsum; 
pass  the  knife  into  the  interosseous  spaces,  separate  the  muscular  at- 
tachments and  divide  the  perios- 
teum, apply  a  five-tailed  retractor 
a  (Fig.  629),  and  saw  the  bone 
with  a  metacarpal  saw. 

7.  Disarticulation  of  the  first 
metacarpal  bone  is  performed  as 
tnllows:  — 

The  joint  is  of  a  mixed  character,  be- 
tween arthrodial  and  fiiniilvnioid;  on  its 
dorsal  surface  it  is  almost  subcutaneous, 
but  covered  with  thick  muscle  on  its 
palmar  aspect ;  the  radial  artery  passes 
around  its  ulnar  side;  it  has  a  loose  capsule;  the  joint  runs  in  an  oblique 
direction,  in  a  line  drawn  from  its  external  side  to  the  root  of  the  little  linger; 
it  is  easily  determined  by  the  projection  of  the  enlargement  of  the  head  of  the 
bone,  on  pressing  the  thumb  into  the  palm;  or,  it  lies  an  inch  and  a  quarter 
below  the  st^ioid  process  of  the  radius. 

Hold  the  hand  in  a  position  between  supination  and  pronation  ; 
make  an  incision  along  the  dorsal  surface  of  the  metacarpal  bone 
of  the  thumb,  commencing  six  lines  above  its  articulation,  a  (Fig. 
630),   with  the   trapezium,  and  extending  through   all  the  tissues 


604 


OPERATIVE  SURGERY. 


Fi(i.  (jyo. 


down  to  the  bone,  to  the  inner  side  of  the  head  of  the  first  phalanx 
of  the  thumb,  on  a  level  with  the  commissure,  b,  between  the  thinub 
and  index  finger;  carrying  the 
hand  to  pronation,  continue  the 
incision  around  the  palmar  sur- 
face of  the  phalanx  to  its  out- 
side, c,  and  thence  to  the  dorsum 
of  the  metacarpal  bone  to  join 
the  first  incision  about  its  mid- 
dle ;  detach  the  muscles  and 
integuments  from  either  side 
of  the  bone,  and  open  the  artic- 
ulation from  its  dorsal  aspect,  a 
(Fig.  630)  ;  then  endeavoring 
I  to  dislocate  the  bone  outwards, 
complete  the  division  of  its  re- 
maining attachments. 

8.  Disarticulation  of  the 
second  metacarpal  bone  is 
rendered  especially  difficult  on 
account  of  the  prolongation  of  that  part  of  its  head  that  is  in  relation 
Avith  the  trapezoid,  os  magnum,  and  third  metacarpal.  The  hand 
held  in  pronation,  the  thumb  and  fingers  separated,  make  an  incis- 
ion, commencing  about  half  an  inch  in  front  of  the  styloid  process  of 
^  the  radius,  but  on  a  line  with  the  second  metacar- 

pal bone,  d  (Fig.  632),  and  continue  to  the  inter- 
nal side  of  the  bnse  of  the  first  phalanx,  a:  now 
,  carry  it  around  the  palmar  surface  in  the  cutane- 
ous fold  —  rejjresented  on  the  dorsum  by  the  line 
h,  c  —  to  the  point  c,  and  thence  to  point  of  com- 
mencement, d ;  dissect  the  soft  parts  by  keeping 
the  knife  close  to  the  bone,  the  wound  being  held 
apart ;  carry  the  knife  up  along  the  internal  side 
of  the  bone  to  the  union  of  the  two  metacarpal 
bones,  and,  turning  its  edge  inward.s,  divide  the 
.(I  interosseous  ligament,  and,  in  the  same  manner, 
enter  the  knife  into  the  articulation  of  the  meta- 
carpal bone  with  tlie  trapezius;  the  anterior  and 
posterior  ligaments  are  next  divided,  the  bone  dislocated,  and  the 
knife  entered  flatwise  and  horizontally  under  the  upper  part  of  the 
bone  a  and  h  (Fig.  633),  is  carried  downwards,  completing  the  oper- 
ation; care  should  be  taken  in  dividing  the  ligaments  not  to  pene- 
trate an}'  adjoining  articular  cavity. 

9.  Disarticulation  of  the  fifth  metacarpal  bone  may  be  per- 
formed by  two  methods:  — 


Fig.  632. 


AMPUTATION. 


COo 


The  unciform  receives  the  fifth  niefacarpal  hone,  upon  a  surface  concave  from 
behind  forwards;  the  line  of  articulation,  if  prolonged,  would  fall  upon  the 
middle  of  the  second  metacarpal  bone. 

(1.)  Proiialf  the  hand  and  coiiiuience  an  incision  one  line  above  the 
articulation  a  (Fitj.  C34),  and  carry  it  alon'j;  the  <lorsiiin  to  tlie  com- 
missure, b,  then  under  tiie  finger,  along  the  fold  of  the   intcgunicnt 


Fig.  633. 


Fig.  634. 


to  the  opposite  side,  and  from  thence  back  to  the  point  of  de- 
parture, a  ;  dissect  the  soft  parts  from  the  bone  and  disarticulate. 
(2.)  (Fig.  634.)  The  hand  being  held  in  a  state  of  forced  pronation, 
commence  an  incision  six  lines  above  the  carpo-metacarpal  joint,  a, 
and  carry  it  down  in  a  straight  line  to  the  inner  border 
of  the  first  phalanx  of  the  little  finger,  until  it  meets 
the  depression  at  the  base  of  the  little  finger,  on  its 
palmar  surface,  h;  then  continue  it  around  the  base  of 
the  finger  following  this  depression  exactly;  and,  lift- 
ing the  little  finger,  continue  the  incision  around  to  its 
inside,  c  (Fig.  634),  and  upwards  to  join  the  first 
portion  about  opposite  to  the  centre  of  the  metacarpal 
bone;  detach  the;  integuments  and  muscles  from  the 
bone,  and  divide  its  articular  connection  with  the  point 
of  the  bistoury  in  the  manner  already  described.  The 
wound  after  the  operation  is  seen  in  Fig.  63.5. 

10.  Disarticulation  of  fourth  and  fifth  metacar- 
pal bones  is  as  follows:  Make  a  transverse  incision  a 
little  in  front  of  the  articulations,  another  parallel  to 
the  axis  of  the  metacarpal  bones,  upon  the   dorsum  of 
the  fifth,  in  order  to  cut  upon  that  part  a  dorsal  flap  which  is  to  cover 


Fig.  635. 


606 


OPERATIVE  SURGERY. 


the  whole  ulnar  side  of  the  wound  after  the  operation  ;  the  disarticu- 
lation is  thus  effected,  and  a  small  flap  formed,  which  must  be  sepa- 
rated down  to  its  base  in  the  palm  of  the  hand,  in  order  to  be  able 
to  raise  it  upon  the  transverse  branch  of  the  wound. ^  The  same  pro- 
cess is  ada])ted  to  any  other  two  metacarpal  bones. 

1 1 .  Disarticulation  of  the  metacarpal  bones  of  the  four  fin- 
gers is  performed  thus  :  Hold  thi^  h;ind  in  the  position  of  forced  su- 
pination and  introduce,  opposite  the  articulation  of  the  fifth  metacar- 
pal with  the  luiciform  bone,  a  small,  straight  knife  between  the  bones 
and  the  soft  parts,  carrying  it  a  little  below  the  projections  formed 
by  the  unciform  and  the  trapezium,  so  as  to  bring  out  its  point  below 
the  thumb;  carry  the  blade  of  the  knife  along  the  palmar  surfaces 
of  the  metacarpal  bones,  and  cut  out  a  large  flap  of  an  elliptical  out- 
line, a,  6,  c  (Fig.  636),  turn  the  hand  in  a  prone  position,  and  make 
a  semicircular  incision  across  its  back,  two  thirds  of  an  inch  below 


Fig.  636. 


Fig.  637. 


the  line  of  the  articulations,  and  carrying  the  knife  through  the  tis- 
sues connecting  the  thumb  with  the  index  finger,  «,  h,  c  (Fig.  636), 
join  the  first  incision;  while  an  assistant  is  drawing  the  integuments 
upwards,  hold  the  metacarpus  in  the  left  hand,  disarticulate  from  the 
front,  commencing  with  the  metacarpal  bone  of  the  index  or  little 
finger,  according  as  the  operation  is  upon  the  right  or  left  hand.^ 

12.  Radio-carpal  disarticulation  gives  the  best  results  when  a 
flap  is  taken  fi'om  the  jialmar  surface  of  the  hand. 

To  determine  the  articulation:  (1.)  Strongly  bend  the  hand  backwards;  the 
summit  of  the  angle  formed  by  it  with  the  forearm  indicates  the  radio-carpal 
articulation.  (2.)  Feel  in  front  the  transverse  process  of  tiie  radius;  the  joint 
is  one  line  below  it,  and  about  half  an  inch  above  the  crease  in  the  skin  tiiat 
separates  the  palm  of  the  hand  from  the  forearm.  (3.)  Determine  the  summit 
of  the  styloid  processes,  and  draw  a  transverse  line  between  them;  this  line  will 
be  two  lines  and  a  half  below  the  joint. 8 

1  Velpeau.  2  Maingault.  ^  Malgaigne. 


AMPUTA  TION. 


607 


A  sinffle  palmar  flap  is  made  as  follows:  An  assistant  holds  the 
hand  in  a  sui)ine  position;  grasp  the  extremity  in  the  palm  of  the 
left  hand,  placing  the  thiiiub  and  forefinger  on  the 
extremities  of  the  styloid  processes;  make  a  semi- 
circular incision  on  ihe  palm  (Fig.  fl.'JS)  from  just 
below  the  processes,  having  its  concavity  n[)wards; 
dissect  the  flap  and  turn  it  back,  and  divide  the 
tendons,  the  radio- 
carpal and  lateral 
ligaments.  Or, 
make  the  first  in-  *>- 
cision  on  the  dor-  " 
sun),  open  the  artic- 
ulation and  pass  the  knife  through 
(Fig.  G39),  forming  a  palmar  flap 
three  inches  in  length. 

13.  Amputation  of  the  forearm 
is  best  |)crt'(>riucd  in  tlu'  lower  part 
by  the  circular,  and  in  the  upper 
part  by  the  flap  method,  for  in  the  Fig.  639. 

h)wer  portion  the  soft  tissues  are  mostly  tendinous,  ami  in  the  upper, 
muscular  ;  its  arteries  are  the  radial,  ulnar,  and  anterior  and  pos- 
terior interosseous;  two  bones  are  to  be  divided,  of  different  diam- 
eters, at  different  parts  of  the  limb. 

(1.)  Tho  circular  operation  is  as  follows:  The  forearm  being  held  in  a  posi- 
tion between  pronation  and  supination,  make  a  circular  incision  through  the 
skin  and  subcutaneous  cellular  tissue;  turn  up  the  skin  like  the  cuff  of  a  coat, 
and  if  it  should  not  retract  easily,  owing  to  the  conical  shape  of   the  limb, 
make  a  lateral  incision;  now  divide  circularly  the  muscles 
\    at  the  border  of  the  flap  of  skin,  and  tin-n  it  over  still  fur- 
ther; then  raise  an  inch  or  more  of  periosteum  from  each 
bone,   incising   it    first   along   its  at- 
tachments on  the  inner  borders  of  the 
bone;  at  the  highest  point  where  the 
bones   are   denuded,  draw   the   saw, 
slowly  at  tir>t,  across  the  radius  and 
ulna,  taking  care  to  saw  through  the 
radius  first  (Fig.  641),  as  the  ulna, 
being  more  closely  attached  to  the  humerus, 
serves  as  a  support  for  the  limb;   tie  the  ra- 
dial, ulnar,  the  anterior  and   posterior  interos- 
seous  arteries;   cleanse  the  wound  with  car- 
bolic solution. 

(2.)  The  flap  may  be  single  or  double.    The 
arm  being  held  in  the  position  between  prona- 
tion  and  supination,  with   the   thumb   upper- 
most, so  that  the  radius  and  ulna  are  iu  one  line,  enter  a  sharp-puir.ted  knife 


I'lu.  640. 


608 


OPERATIVE  SURGERY. 


close  to  the  inner  edge  of  the  radius  and  bring  it  out  opposite  at  the  edge  of  the 
ulna;  if  a  single  flap  is  to  be  made,  it  must  l)e  taken  from 
the  anterior  face,  and  be  lung  t-nminh  to  ((inipiett-jy  cover  tlic 
stump ;  if  a  double  flap 
is  preferred,  make  an 
anterior  flapthe  length 
of  half  the  diameter 
of  the  arm,  and  a  pos- 
terior flap  of  equal 
length;  turn  back  the 
flaps,  divide  the  tendi- 
nous muscular  or  in- 
terosseous fibres  not 
cut  through,  and  di- 
vide the  bones  as  in 
the  circular  operation. 
Bilateral  flaps  of  the 
integunients  and   cir 


Fig.  641. 


cular  incision  of  the  muscles  is  often  preferred,  to  avoid  projection  of  the  ulna.i 
The  rectangular  flap  ^  niethod  is  also  adapted  to  the  lower  part  of  the  forearm. 

14.  Amputation  of  the  elbowr-joint  is  to  be  preferred  to  ampu- 
tation through  the  arm,  if  no  artificial  arm  is  to  be  applied,  as  tlie 
stump  is  broad  and  firm,  and  can  be  made  more  useful.  The  cir- 
cular and  single  anterior  flap  methods  are  adapted  to  this  articula- 
tion. 

The  exact  position  of  the  joint  is  determined  by  careful  attention  to  the  ana- 
tomical relations  of  the  following  osseous  prominences  about  the  joint:  the  epi- 
condyles,  or  the  most  prominent  points  on  the  condyles  of  the  os  brachii,  b,/",  c 
(Fig.  043),  are  lecognized,  the  internal  more  readily  than  the  external;  also  the 
olecranon,  c(Fig.  643),  a  line  drawn  through  the  lower  points  is,  on  the  outside, 
a  quarter  of  an  inch 
above  the  intcrarticular 
line,  b,f,  c  (Fig.  642), 
and  on  the  inside  three- 
quarters  of  an  inch;  the 
articulation  of  the  radius 
/■•  and  humerus  is  trans- 
8  verse,  that  of  the  ulna 
irregular,  and  owing  to 
,1  its  projections,  must  be 
entered  externalh'.  Two 
facts  result :  first,  that 
the  articular  interline  is 
very  oblique  from  with- 
out inwards  and  from 
second,  that  it  is  very  much  below  the  tuberosities  of  the 
humerus.  If  then,  in  cutting  the  anterior  flap,  its  base  is  extended  up  to  the 
level  of  these  tuberosities,  it  will  almost  always  be  too  short  to  cover  the  bone, 


Fig.  642. 
above  downwards 


Fig.  643. 


1  F.  C.  Skey. 


2  Teale. 


AMPUTATION. 


G09 


which  will  project,  especially  on  the  inside  and  downwards;  therefore,  enter  the 

knife  one  inch  helow  the  middle 
projection  of  the  epitmelilca,  to 
brin^  it  out  half  an  inch  helow  the 
projection  of  the  e])i(()ndyle.' 

(1.)  The  circular  method  is  as 
follows:  The  arm  being  held  in  a 
supine  position  make  a  circular  in- 
cision throuf^li  the  skin  only,  three 
to  four  inches  below  the  joint;  dis- 
sect up  the  integuments  to  the  joint, 
and  reflect  backwards,  a,  b  (Fig. 
644);  divide  the  muscles  in  front, 
and  the  ligaments,  enter  the  joint 
and  complete  the  disarticulation  by  divid- 
ing the  triceps,  or  sawing  otT  the  olecranon; 
the  brachial  artery  is  divided  above  its  bi- 
furcation. 

(2.)  The  single  anterior  flap  is  made 
thus:  Supinate  and  slightly  flex  the  limb; 
raise  the  soft  parts  from  the  bone  in  front 
of  the  joint,  enter  a  straight  knife  an  inch 
beiow  the  internal  condyle,  traverse  the 
limb  close  to  the  ulna,  until  it  appears  one 
and  three-quarter  inches  below  the  exter- 
nal condyle,  to  allow  for  retraction  of  mus- 
cles arising  fmni  the  humerus;  cut  an  an- 
terior flap,  rt,  b,  c  (Fig.  045),  about  three 
inches  in  length;  retract  this  flap,  a  (Fig. 
646),  and  pass  the  knife  behind  the  limb,  PlQ    g^g 

and  enter  the  heel  on  the  outside  between 

the  radius  and  os  brachii,  e,  and  extend  the  incision,  draw  it  across  the  back 
part  of  the  joint,  dividing  all  the  tissues  to  the  internal  angle  of  the  wound; 


Fio.  646. 


divide  the  anterior  ligament,  c,  rf  (Fig.  040),  and  the  lateral  ligaments,  luxate 
the  bones  forwards,  cut  the  triceps  and  complete  the  operation. 

1  J.  F.  Malgaigne. 
39 


610 


OPERATIVE  SURGERY. 


(3.)  An  external  flap  may  be  preferred  in  some  cases  of  accident  :i  Make 
the  flap  by  transfixing  the  limb  upon  the  outside,  enterint;-  the  point  of  the  knife 
just  within  the  head  of  the  radius,  a  (Fig.  647),  traversing  the  neck,  c,  and 
cutting  out  a  larger  external  flap,  b  ;  a  second  flap  is  made  from  the  inside  of 
the  arm,  by  cutting  from  witiiout  inwards,  and  from  below  upwards,  cZ;  the 
soft  tissues  immediately  covering  the  joint  are  divided,  and  disarticulation  com- 
pleted: a  good  covering  is  thus  made  for  the  condj-les. 

15.  Amputation  of  the' arm  may  be  performed  at  any  point,  but, 
as  a  rule,  as  little  sliuuld  be  sacrificed  as  possible.  Owing  to  its  uni- 
form size,  and  single  central  bone,  any  of  the  different  methods  may 
be  applied,  but  the  periosteum  should  always  be  raised,  as  a  cover- 
ing to  the  bone. 

The  humerus  is  covered  in  its  lower  part  by  muscles  closely  attached;  in  the 
upper  part  large  muscles  are  inserted  into  it,  which  have  their  origin  from  the 
thorax,  shoulder,  and  back,  which,  when  divided,  tend  to  retract  and  leave  the 
bone  l)are;  the  only  artery  always  requiring  the  ligature  is  the  brachial. 

(1.)  The  circular  is  as  follows  :  Place  the  arm  at  right  angles  to  the  bodj-; 
standing  on  the  right  side  of  the  limb,  make  a  circular  incision  through  the  in- 
teguments; roll  the  flap  one  to  two  inches,  according  to  the  size  of  the  limb; 
nial^e  a  second  incision  at  the  margin  of  the  retracted  skin;  divide  and  retract 
the  superficial  muscles,  and  make  a  third  incision  down  to  the  bone;  raise  the 
periosteum  an  inch,  and  saw  the  boue;  secure  the  brachial  artery  which  lies  on 
the  inside,  between  the  biceps  and  internal  portion  of  the  triceps  muscles;  car- 
bolize  the  wound,  and  bring  the  edges  together  from  before  backwards;  it  may 
be  closed  from  side  to  side,  or  even  obliquely. 

(2.)  The  flap  maybe  single  and  may  be  made  at  any  point  presenting  on  one 
surface  a  sutHeient  amount  of  tissues;  two  flajisof  equal  size  are  generally  ante- 
rior and  posterior;  the  arm  being  carried  at  a  right  angle  with  the  body,  grasp 
with  the  left  hand  the  tissues  on  the  anterior  or  lateral  part  of  the  arm,  and  pass- 
ing the  knife  down  to  the  bone,  carry  it  over  to  the  opposite  side,  and  cut  out  a 
flap  three-fourths  the  diameter  of  the  limb  in  length  (Fig.  648),  enter  the  knife 
close  to  the  bone  on  the  opposite  side,  and  make  a  similar  flap;  firmly  retract  the 

flaps,  divide  the 

tissues   covering 

the     bone,    and 

saw  the  bone  in 

the  highest  point 

between  the  flaps 

(Fig.  649).  If  one 

flap    is    formed, 

grasp  the  tissues 

on    the    anterior 

part  of  the  limb, 

placing     the 

thumb    and    in- 
dex finger  at  op-  — 

posite   points;  1"  iG-  049. 

with  the  left  hand  above  the  place  of  operaticni,  fix  the  heel  of  the  knife  at  the 
point  of  the  fingers,  on  the  opposite  side  of  the  limb,  and  with  a  slight  down- 
1  A.  Gu^rin. 


Fio.  648. 


AMPUTATION. 


Gil 


ward  curve  hriiifc  it  over  to  tlie  (loiiit  of  tlic  tliiinib,  divirtinp  with  one  stroke 
the  tissues  to  the  bone;  wididraw  the  knife  until  (he  point  rests  in  tiie  angle  of 
tiie  wound,  then  thiust  it  under  and 
close  to  the  hone,  taking  care  that 
the  point  enieif^es  at  the  angle  of 
the  lir»t  cut  on  the  opposite  side 
where  the  incision  commenced  ; 
make  a  flap  of  sulficient  length  to 
cover  the  stump ;  divide  the  re- 
maining soft  parts  with  a  circular 
incision,  and  saw  the  bone  in  the 
line  of  division. 

(■J.)  The  rectangular  flap   method   may  also   ite 
performed  on  the  lower  |iart  of  the  arm,  the  line  of  in-  Fig.  G.jO. 

cision  being  followed  according  to  the  rules  specified. 

16.  The  shoulder  joint  may  be  disarticulated  V)v  sevcnil  iiath- 
ods.  This  joint  is  arthrodial ;  the  articidar  head  of  tlie  os  hrachii 
is  very  broaii,  and  articulates  by  scarcely  one  third  with  the  shallow 
glenoid  cavity  of  the  scapula;  it  is  connected,  too,  by  a  loose  cap- 
sular ligament;   the  joint  is  strengthened  by  the  long  head  of  the 

biceps,  and    the 
muscles    arising 
from  the  scapu- 
la  and    inserted 
in  the  vicinity  of 
the    joint  ;    the 
joint  is   p  r  o  - 
ticted  above  by 
the  extremity  of 
the  clavicle,  and 
the  acromion 
process.     Tlu;    artery  must  be  compressed  on  the  first  rib  with  the 
thumb  or  a  padded  key  above  the  clavicle  ;  or  the  elastic  tube  may 
be  applied  through  the  axilla  and  over  the  shoulder  (Fig.  651). 

The  oval  method  ^  is  still  most  in  favor.  Make  a  vertical  incis- 
ion from  the  edge  of  the  acromion  process  to  a  point  one  inch  below 
the  top  of  the  humerus  down  to  the  bone  (Fig.  652).  INIake  two 
ol)li(jue  incisions  starting  from  the  middle  of  the  vertical  one  on  the 
anterior,  the  other  on  the  posterior  aspect  of  the  joint,  carrying  them 
through  the  tissues  composing  the  anterior  and  posterior  walls  of 
the  axilla,  to  the  lower  border  of  each,  and  dividing  their  attach- 
ments to  the  humerus.  Push  the  edges  of  the  wound  on  either  side 
to  expose  the  joint,  and  open  it,  making  traction  on  the  bone  to  put 
its  ligament  on  the  stretch;  lu.xate  the  bone,  pass  the  knife  behind  it 
(Fig.  653)  and  finish  the  operation  by  cutting  directly  through  the 

1  Larrey. 


Fig.  G51. 


612 


OPERATIVE  SURGERY. 


tissues  in  the  axilla,  which  intervene  between  the  extremities  of  the 
incisions  already  made,  recollecting  that 
they  contain  the  artery,  which  requires 


Fig.  052.  FiG.  653. 

to  be  compressed  by  an  assistant.  The  wound  which  results  from 
this  operation  is  almost  perfectly  oval  in  shape.  Or,  the  head  of  the 
bone  may  be  dissected 
from  its  cavity,  with  the 
knife  held  vertically, 
first  upon  one  side  and 
then  upon  the  other,  a, 
h,  c  (Fig.  654).  and  com- 
pleted by  dividing  the 
axillary  portion.^ 

1.  The  single  flap  meth- 
od''^ is  as  follows  :  The  arm 
beini;  held  away  from  tlie 
trunk,  grasp  the  deltoid  in 
its  entire  length  and  thick- 
ness in  the  left  hand;  and 
with  the  right  pass  a  double 
edged  knife  through  its 
base,  under  the  acromion, 
and  grazing  the  surface  of 
the  humerus,  cut  an  exter- 
nal and  superior  flap  of  sufficient  extent;  an  assistant  raises  it;  then,  by  ap- 
proaching the  arm  to  the  body,  expose  the  tendons  of  the  muscles  inserted  into 
the  head  of  the  iiumerus  and  cut  them;  grasping  the  arm  with  the  left  hand, 
dislocate  the  head  of  the  bone  outwards,  pass  the  knife  behind  it  and  incise  the 
soft  parts,  while  an  assistant  seizes  the  flap  in  such  a  manner  as  to  prevent 
haemorrhage  from  the  divided  axillarj'  artery,  and,  if  the  tissues  are  hardened, 
1  Gu^rin.  ^  Dupuytren. 


Fig.  654. 


AMPUTATION. 


Gi;i 


taking  great  care  not  to  allow  air  to  enter  the  veins. l  The  flap  nii;;Iit  be  made 
by  cutting  from  without  inwards,  commenciuf^  the  incision,  on  the  left  side, 
near  tlie  anterior  border  of  tlie  del- 
toid, on  a  level  with  tiie  articulation; 
descend  in  a  curved  line  to  within 
two  thirds  of  an  inch  of  the  insertion 
of  the  deltoid,  and  then  ascending  on 


Fig.  655. 


Fig.  656. 


the  posterior  part  (Fig.  655)  to  the  same  level  as  it  was  commenced ;  dissect  up 
the  flap,  and  disarticulate  the  limb-  as  before. 

2.  The  double  flap^  is  as  follows:  The  arm  is  kept  close  to  the  trunk,  the 
head  of  the  humerus  being  pushed  upwards  and  outwards  as  much  as  possible; 
recognize  the  exact  position  of  the  acromion  and  cora-  a 

coid  processes;  on  the  left  shoulder  enter  the  point  of  a 
long  knife  almost  parallel  with  the  humerus  at  the  out- 
er side  of  the  posterior  border  of  the  axilla,  in  front  of 
the  tendons  of  the  latissimus  dorsi  and  teres  ma- 
jor muscles,  c  {Fig.  656).  As  the  knife  pusses  in 
the  plane  of  its  blade  it  should  form  an  angle  of 
thirty-five  degrees  with  the  axis  of  the  shoulder,' 
and  its  point  should  graze  the  posterior  and  ex-« 
ternal  surface  of  the  humerus,  until  it  reaches 
the  under  surface  of  the  acromion  ;  at  this  point. 
the  handle  of  the  knife  should  be  raised,  and  its 
point  lowered  so  that  it  is  brought  out  below  and, 
in  front  of  the  clavicle,  a,  in  the  triangular  space 
between   the   acromion   and    coracoid  processes,    which    is 
bounded  posteriorly  by  the  clavicle.     Make  the  knife  cut 
its  wa_v  outwards  around  the  head  of  the  hinnerus,  b,  and 
as  soon  as  it  becomes  disengaged  from  beneath  the  acromion 
process,  carry  the  arm  away  from  the  trunk  ;  now  grasp  the 
deltoid  muscle  with  the  left  hand,  raising  it  as  much  as  pos- 
sible from  the  bone,  and  carry  the  knife  directly  downwards, 
grazing  the  bone,  and  cut  out  a  semicircular  flap  about  three  inches  in  length. 
In  making  this  flap  the  upjier  part  of  the  capsule  of  the  joint  should  be  divided 
as  well  as  the  tendons  of  the  latissimus  dorsi,  teres  major  and  minor,  and  part  of 
the  deltoid  ;  raise  the  head  of  the  humerus  from  the  glenoid  cavity,  pass  the 

1  S-  D.  Gross.  2  X.  Guerin.  8  Lisfranc. 


Fiff.  C57. 


614 


OPERATIVE  SURGERY. 


blade  of  the  knife  behind  it,  and  carry  it  downwards  and  forwards,  grazing  the 
humerus,  to  cut  out  the  internal  flap,  and  at  this  moment  the  axillary  artery 
should  be  compressed  by  an  assistant.  In  operating  on  the  right  shoulder,  the 
same  rules  are  followed,  except  that  the  knife  should  be  entered  in  the  infi'a- 
clavicular  triangle,  c  (Fig.  657),  and  brought  out  at  tiie  posterior  border  of  the 
axilla,  a,  thus  reversing  the  direction  of  the  knife  in  transfixing  the  articulation, 
to  cut  out  the  posterior  flap. 

AMPUTATION  OF  THE  LOWER  EXTREMITY. 

Under  all  circumstances,  except  where  poverty  and  advanced  age, 
and  confirmed  dissolute  habits,  so  combine  in  the  individual  as  to 
render  it  certain  that  mechanical  appliances  would  be  of  little  ser- 
vice, give  the  patient  the  stump  best  adapted  to  the  most  useful  ar- 
tificial limb.  In  all  amputations  of  the  lower  extremity,  the  surgeon 
should  be  governed  in  the  selection  of  the  point  of  o])eration  and  the 
method  to  be  adopted  :  (1.)  By  the  mortality  of  the  operation  in 
question;  (2.)  By  the  adaptability  of  the  stump  to  the  most  service- 
able artificial  limb  for  locomotion. ^ 

1.  Amputation  of  the  phalanges  in  the  continuity  or  contiguity 
is  performed  i)y  the  same  rules  as  have  been  given  for  similar  amputa- 
tions of  the  fingers;  a  flap  being  generally  formed 
from  the  plantar  surface. 

2.  Disarticulation  of  single  toes  must  be 
undertaken  with  due  regard  to  the  following 
facts,  viz.,  the  extremity  of  the  first  metatarsal 
bone,  1  (Fig.  658),  is  large, 
and  requires  a  very  liberal 
flap  to  cover  it;  on  the  plan- 
tar face  of  the  artic- 
ulation  are  two  or  '  - -. 
three  sesamoid  bones; 
the  interarticular  line  is  fur- 
ther from  the  interdigital 
fold  than  in  the  hand,  but 
the  second  space  is  much 
nearer  the  joint  than  the 
others. 

(1.)  The  oval  method  is 
as  follows:  Holding  the  toe 
with  the  finger  and  thumb, 
commence  an  incision  over  the  joint,/  (Fig.  659),  and  carry  it  down- 
wards and  forwards,  along  the  side  of  the  toe  to  the  commissure  of 
the  toes,  around,  under  the  toe,  along  the  transverse  linear  depres- 

1  Report  of  Drs.  Valentine  Mott,  Gurdon  Buck,  John  Watson,  Alfred  C.  Post, 
Willard  Parker,  Ernst  Krackowizer,  W.  H.  Van  Buren,  and  Stephen  Smith. 


Fig.  658. 


AMPUTATION. 


615 


sion  to  the  opposite  side,  and  thence  up  to  the  point  of  commence- 
ment; divide  the  extensor  tendons  and  lateral  ligaments  with  the 
point  of  the  knife,  open  the  joint,  and  coniplete  the  disarticulation  hy 
cutting  the  tissues  upon  the  under  part  of  the  joint. 

(2. )  The  single  plantar  flap,  for  the  second,  third,  and  fourtli  toes,  requires  a 
transverse  incision  over  the  joint,  and  hiteral  incisions  to  divide  its  connections; 
depress  the  toe,  and  pass  the  knife  thronj^h  tiie  joint  and  aionj^  tlie  under  sur- 
face of  till-  bone  until  a  sullicient  flap  is  formed.  The  lateral  flap  for  the  great 
and  for  tlie  little  toe  is  made  thus  :  enter  the  joint  by  cuttinj;  tinougii  the  com- 


FiG.  600. 


I-ir..  GGl. 


missure,  tlie  knife  beinff  held  vertically,  and  complete  the  operation  by  carrying 
the  knife  throuf^b  tlie  joint  and  along  the  outer  or  inner  side  of  the  bone,  form- 
ing a  flap  of  the  requisite  size  (Figs.  CGO,  001). 

(3.)  The  double  flap  is  tlins  made:  holding  the  toe  in  the  left  hand,  and, 
recognizing  the  articulation,  transti.x  the  soft  parts  by  passing  the  knife  from  the 
plantar  to  the  dorsal  surface  on  one  side,  emerging  over  the  middle  of  tlie  joint, 
and  cutting  a  flap  from  the  side  as  far  as  the  edge  of  the  commissure;  open  the 
joint  on  the  side,  pass  the  knife  through  and  cut  a  flap  from  the  opposite  side, 
by  passing  the  knife  along  tiie  bone;  or,  the  second  flap  may  be  cut  by  transfix- 
ing as  the  first.  Or,  amputate  the  toe  thus:  bend  the  toe  downwards,  and 
make  a  dorsal  flap  across  the  middle  of  the  phalanx,  from  the  integnmental 
fold,  between  it  and  the  second  toe,  to  the  side  of  the  ball  of  the  first  toe,  and 
reflect  it;  a  similar  line  below,  uniting  the  ends  of  the  first  flap  by  a  circular 
sweep  of  the  knife,  forms  the  lower  flap;  disarticulate  the  bone,  and  complete 
by  cutting  out  the  lower  flap.  Or,  make  a  straight  longitudinal  incision  along 
the  inner  side  of  the  toe,  commencing  about  half  an  inch  Ijeliind  the  articula- 
tion, and  carry  it  onwards  to  the  middle  of  the  first  phalanx. 

3.  Disarticulation  of  all  of  the  toes  is  throii^li  tiie  metatarso- 
phalangeal articiilatidiis. 

These  joints  (Fig.  658)  represent  a  curved  line  with  its  convexity  downwards, 
due  to  the  difference  in  the  metatarsal  bones;  the  second  is  a  half  a  line  longer 
than  the  tirst,  the  third  is  a  lialf  a  line  shorter  than  the  second,  the  fourth  is 
half  a  line  behind  the  third,  the  fifth  is  still  further  behind. 


616 


OPERATIVE   SURGERY. 


The  single  flap  is  made  in  nearlj'  the  same  manner  as  in  amj)uta- 
tion  of  all  the  fingers;  the  incision,  a,  h,  c,  in  relation  to  the  joints, 
is  seen  in  Fig.  662.  If  the  operation  is  on  the 
left  foot,  grasp  the  toes  with  the  left  hand,  the 
thumh  applied  to  the  backs  of  the  toes,  and 
make  a  seniicircular  incision  in  front  of  the 
joints,  commencing  at  the  internal  side  of  the 
head  of  the  first  metatarsal  bone,  and  ending  at 
the  external  side  of  the  fifth  ;  dissect  up  the  flap, 
open  the  joints,  and  divide  the  lateral  ligaments 
with  the  point  of  the  knife;  now  pass  the  knife 
behind  the  phalanges  and  cut  a  flap  from  the 
plantar  surface.  Or,  make  the  plantar  flap  by 
Fin'.  (JU2.  extending  an  incision  along  the  cutaneous  fold 

at  the  base  of  the  phalanges  and  dissecting  backwards  (Fig.  663). i 
4.  Amputation   through  the   metatarsal  bones   is  performed 
with  jjiantar  and  dorsal  flaps,  as  on  the 
metacarpus.  IVIake  a  curved  incision  on 
the  dorsum  of  the  foot,  convex  down- 
wards, dividing  the  soft  parts  down  to 
the  bone;  trans- 
fix the  plantar 
surface,  grazing 
the   bones,  and 
m  a  k  e    a    fl  a 
reaching  to  the  com- 
missure of   the   toes; 
divide    the  interosse- 
ous muscles  with  the 
point    of    the    knife, 
apply   a  sixtailed  re- 
tractor,    and      divide 
the  bones  with  a  fine 
saw  (Fig.  6G4).  Pjj,    q^^, 

5.  Disarticulation  of  the  first  metatarsal  bone  is  best  per- 
formed by  the  oval  method. 

It  has  four  ligaments,  an  internnl,  dorsal,  plantar,  and  interosseous  ;  the  ar- 
ticulation is  one  or  two  lines  behind  the  first  projection  found  on  the  posterior 
portion  of  the  metatarsal  bone,  and  an  inch  anterior  to  the  prominence  of  the 
scaphoid,  e  (Fig.  058);  the  direction  of  the  line  of  articulation  is  from  within 
forwards  and  outwards;  the  dorsalis  pedis  artery  passes  to  the  sole  of  the  foot 
on  the  outer  side  of  the  joint. 

1  Guerin. 


AMPUTATION. 


617 


I'iG.  CG5. 


Commence  two  lines  behind  the  joint,  a  (Fig.  CG.'j),  an  incision  di- 
rected obliquely  from  within  outwards,  to  the 
commissure  of  the  toes,  c,  and  pass  around  the 
base  of  the  first  phalanx,  follow- 
ing the  crease  on  its  plantar  sur- 
face; withdraw  the  bistoury  and 
replace  it  on  the  internal  side  of 
the  phalanx,  h,  in  the  inferior 
angle  of  the  incision,  ascend  on 
the  internal  side  of  the  metatar- 
sal bone  and  phalanx,  and  follow- 
ing a  line  sliL^htly  oblicpie  from  within  outwards,  rejoin  the  point  of 
commencement;  the  skin  being  cut,  divide  successively  in  the  whole 
extent  of  the  incision  the  extensor  tendons  of  the  toe  and  fiijres  of 
the  dorsal  interosseous  muscle.  Dissect  out  the  bone,  leaving  the 
sesamoid  bones  in  the  phalangeal  articulation,  divide  the  internal 
ligament,  holding  the  point  of  the  instrument  perpendicnlnrly  and  the 
edge  slightly  oblique  from  within  outwards  and  from  behind  forwards 
to  follow  the  direction  of  the  joint;  next,  divide  the  superior  liga- 
ment, and  direct  the  bistoury  upwards  and  push  its  i)oint  at  an 
angle  of  forty-five  degrees  into  the  interosseous  space,  formed  by 
the  external  surface  of  the  first  cuneiform  and  the  extremity  of  the 
second  metatarsal  bone;  when  the  point  has  penetrated  to  the  plantar 
layer,  raise  the  blade  again  to  the  perpendicular  and  divide  the  in- 
terosseous ligament. 

6.  Disarticulation  of  the  fifth  metatarsal  bone  is  by  the  oval 
method. 

This  bone  articulates  with  the  cuboid, /(Fi^'.  G58),  by  a  triangular  surface,  and 
with  the  fourth  metacarpal ;  it  lias  a  tubercle  on  the  external  part  of  its  base, 
which  is  easily  felt  and  into  which  is  inserted  the  peroneus  brevis  muscle;  the 
line  of  the  articulation  is  obliquely  forwards  and  inwards. 

Commence  an  incision  just  behind  the  joint,  a  (Fig.  6G6),  carry  it 
,5  forwards  towards  the  commissure,  b, 
/  thence  under  the  toe,  along  the 
transverse  linear  depression  to  the 
ojiposite  side,  c,  and  then  along  the 
external  margin  to  a,  the  point  of 
de])arture  ;  dissect  the  soft  parts  from 
the  bone  and  enter  the  joint  found 
just  behind  the  tubercle;  froni  the 
outside,  divide  the  ligaments  whirh 
unite  it  to  the  fourth  metatarsal,  and  complete  the  operation  i)y  di- 
viding the  plmtnr  ligaments. 

7.  Disai'ticulatiou  of  single  metatarsal  bones  may  be  made  by 


Fk;.  flfiO. 


618 


OPERATIVE  SURGERY. 


Idlt 


the  oval  metho<l.  Commence  an  incision  just  behind  the  joint,  a 
(Fig.  665),  carry  it  forwards  towards  the  commissure,  c,  thence  un- 
der the  toe  along  the  transverse  linear  depression  to  the  opposite 
side,  6,  and  terminate  at  a,  the  point  of  beginning;  dissect  the  soft 
parts  from  the  bone  and  cut  the  ligaments  uniting  it  to  the  third 
and  fifth  metatarsal  and  cuboid,  and  complete  by  dividing  the 
plantar  ligaments. 

8.  Disarticulation  of  the  t^wo  outer  metatarsal  bones  is  made 
follows:   Commence  an  incision  a  finger's  breadth 
id  the  joint  of  the  fifth  metatarsal  bone,  in  the 
le,    between   the   articulation   of  the   two  bones; 
it  forwards  to  the  commissure,  then  along  the 
surface  in  the  transverse  line  to  the  outer  side 
the  little  toe,  and   thence  back  to  the  beginning; 
dissect   the   soft  parts  from   the   bones,   divide 
the  lateral  ligament,  and  disarticulate  the  joints 
by  entering  them  from  the  outside,  and  follow- 
ing the  line  above  given  (Fig.  667). 

9.  Disarticulation  at  the  tarso-metatarsal 
articulation  is  effected  as  follows:  First  recog- 
nize the  exact  line  of  the  articulation. 

On  the  inner  side  of  the  foot  just  posterior  to  tlie  pro- 
jection on  the  base  of  the  first  metatnrsal  bone,  or  one  inch  anterior  to  the  prom- 
inence of  the  scaphoid,  e  (Fig.  657),  on  the  outer  > 
margin  of  tlio  foot,  the  finger  readily  detects  the 
prominence  of  the  posterior  part  of  the  metatar- 
sal bone,  immediately  behind  which  is  the  artic- 
ulation. Care  should  be  taken  not  to  overlook 
the  slight  tubercle  at  the  base  of  the  first  meta- 
tarsal bone  and  not  to  mistake  it  for  the  prom- 
inence of  the  cuneiform  bone. 

Rotate  the  foot  moderately  inwards;  rec- 
ognize exactly  the  line  of  the  articulation 
—  the  internal  extremity  of  which  is  nine 
lines  further  forwards  than  the  external  — 
by  the  rules  already  laid  down;  grasp  the 
foot  with  the  left  hand,  placing  the  thumb 
on  the  outer  side  of  the  proximal  end  of 
the  fifth  metatarsal  bone,  a  (Fig.  668), 
and  the  index  finger  at  the  internal  ex- 
tremity of  the  articulation,  h;  make  a 
semilunar  incision  with  its  convexity  look- 
ing downwards,  from  without  inwards, 
across  the  dorsum  of  the  foot,  passing 
about  a  half  an  inch  below  the  articulation  down  to  the  bones ; 


Fig.  668. 


divide 


AMPUrATIOy. 


619 


Fig.  CG9 


tlie  dorsal  ligaments  with  tlit-  point  of  llu;  knife,  carrying  it  along  tlie 
line  of  the  artienlation  from  without  inwards,  recollecting  that  the 
articulation  of  the  second  metatarsal  lies  f(nu*  lines  hehind  ihe  first 
and  third  ;  this  mortise,  containing  the  head  of  the  second  metatar- 
sal, is  opened  hy  entering  the  knife  between  the  internal  cuneiform 
an<l  tin'  hi'iid  of  the  first,  its  edge  being  turned  upwanls  and  niakino' 
an  angle  of  forty-five  degrees  with  the 
i  axis  of  the  foot  (Fig.  GG9);  now  carry  the 
knife  up  to  a  right  angle,  its  point  trav- 
ersing the  whole  of  tlie  in- 
ner surface  of  the  mortise, 
in  order  to  insure  the  di- 
vision of  the  interosseous 
ligament  ;  then,  divide  that 
on  outer  surface,  depress 
the  metatarsus  to  separate 
fthe  articular  surfaces,  and 
livide  the  remaining  liga- 
mentous attaclimcHts,  es- 
pecially on  the  plantar 
aspect  of  the  articulation,  so  that  the   knife  may  be  readily  carried 

^  beneath    the    heads    of    the 
-'      metatarsal  bones;  cut   out  a 
flap   somewhat  larger  at  its 
internal  than  at  its  external 
])art,    fi'om    the    sole   of   the 
foot  (Fig.  G70)  and  extend- 
ing internally  nearly   to  the 
base  of  the  great  toe;  exter- 
nallv  it  may  be  of  less  extent.      Do  not 
include   the 
s  cs  a  mo  i  d 
loufs  in  the 


Or,  a  plant- 
ar   riaf)   may 
1)0  made    by 
Fig.  670.  carryiiij;      a 

curved   ini-ision  from  the   internal  extremity 
of  the  dorsal  incision  (Y\f^.  G71)  to  the  sesa- 
moid bones,  then  curvinp  forward  across  the 
sole  of  the  foot  to  the  junction   of  the  anterior,  with  the  middle  thiixt  of  the 
fifth  metatarsal  bone,  thence  to  the  l)ei;innin.!j  of  the  dorsal  incision. 

10.  Disarticulation,  medio-tarsal,-'  is  now  rarely  performed,  as 
the  ankle-joint  amputation  ^  gives  far  more  satisfactory  results. 
1  Lisfranc.  2  Chopart.  3  J.  Syme. 


620 


OPERA  Tl  VE  S UR GER Y 


The  line  of  articulation  is  determined  as  follows:  (1.)  On  the  internal  side  of 
the  foot  it  lies  one  inch  in  front  of  the  internal  malleolus;  or,  the  first  tuberosity 
in  front  of  the  internal  malleolus  is  that  of  the  scaphoid,  and  the  joint  is  just 
beliind  it.  (2.)  On  the  external  side  it  is  six  lines  behind  the  prominence  of  the 
fifth  metatarsal  bone  ;  or,  it  is  in  front  of  the  first  tuberosity  anterior  to  the  ex- 
ternal malleolus,  which  is  on  the  os  calcis.  (3.)  The  centre  of  the  articulation 
is  immediately  in  front  of  the  head  of  the  astragalus,  which  is  made  prominent 
by  extending  and  abducting  the  foot.  The  line  of  the  articulation  is  changed 
according  as  the  foot  is  flexed  or  extended  ;  when  it  is  flexed,  the  astragalus 
and  calcaneum  are  almost  on  the  same  line;  when  extended,  the  calcaneum  is 
at  least  three  lines  in  front. 

Operate  thus  :  Holding  the  foot  (left)  in  the  left  hand,  place  the 
thumb  on  the  outside  of  the  joint  and  the  index  or  medius,  on  the 
tuberosity  of  the  scaphoid;  make  a  semilunar  incision  between  these 
two  points,  the  middle  of  wliich  is  half  an  incli  beyond  the  articula- 
tion ;  then,  passing  the  heel  of  the  knife  under  the  left  thumb,  its 
handle  inclined  as  above,  open  the  joint  in  the  direction  pointed  out; 
when  the  joint  is  half  opened,  carry  the  knife  in  front  of  the  head  of 
the  astragalus,  cut  the  dorsal  ligaments  without  penetrating  between 
the  bones;  and,  lastly,  carrying  the  knife  to  the  other  side  of  the 
the  foot,  the  heel  inclined  towards  the  toes  at  an  angle  of  forty-five 
degrees,  finish  opening  the  external  side  of  the  joint;  the  dorsal  liga- 

thus  divided,  push  the 
ife  under  the  external 
and  anterior  side  of 
the  astragalus,  with 
its  edge  directed  for- 
wards, and  cut  the 
interosseous  ligament 
in  the  direction  of  the 
articular  surface  of 
the  calcaneum  ;  the 
joint  is  noAv  wide 
open ;  carry  the  knife 
under  the  plantar  lig- 
aments, and  j)ass  it 
Fig.  G72.  under     the      bones, 

grazing  them,  to  cut  a  sufficient  flap  (Fig.  672),  avoiding  the  pro- 
tuberances of  the  cuboid  and  scaphoid,  and  further  on,  of  the  first 
and  fifth  metatarsal  bones;  the  foot  during  this  time  is  held  in  the 
horizontal  position  ;  raise  the  handle  of  the  knife  slightly,  to  follow 
more  exactly  the  concavity  of  the  tarsus  and  metatarsus. 

11.  Disarticulation  of  the  tarsus  under  the  astragalus  has 
been  practiced,  but  is  not  to  be  preferred  to  amputation  at  the  ankle 
joint,^  except  in  very  rare  cases.      Operate  as  follows:  -^  — 

1  J.  Svme.  2  J-  Roux. 


AMPUTATIOy. 


021 


Commence  an  incision  on  the  posterior  an<l  external  face  of  (lie  Ciilcaneum, 
and  carry  it  forward  below  the  extfrnai  niaiieolus  to  a  point  half  an  inch  ante- 
rior to  tln^  articulation  of  tlie  astraj^alus  in  front;  then  carry  it  to  the  internal 
border  of  the  foot,  and  from  thence  olilirinely  backwards  across  the  plantar  sur- 
face to  the  point  of  departure;  the  flap  is  thus  made  from  the  entire  intcji^ument 
of  the  heel.  Or,  i  commence  the  incision  at  about  the  same  point,  and  carry 
it  forward  to  within  one  inch  of   the  posterior  and  internal  extremity  of  the 

fifth  metatarsal  bone,  thence  with  a  down- 
re  across  the  dorsum  of  the  foot 
iddle   of   tlic    internal   cuneiform 
nee   across   the   sole  of   the  foot 
from    within     outwanls,    and 
from  before  backwards  to  the 
commencement.      Or,-    make 
the     same     incision    until     it 
reaches  the  internal  border  of 
the  foot;    then  carry  it  trans- 
versely across  the  plantar  sur- 
face to  the  posterior  extremity 
of   llie    fifth    metatarsal,    then 
backwards  and    obliquely  up- 
Fin.  6i3.  wards  alonj;  the  external  sur- 

face of  the  foot  to  the  point  of  departure  (Fip.  673).  It  may  be  reversed,  pass- 
ing in  the  opposite  direction,  under  the  font,  from  the  external  to  the  internal 
side.  In  the  dissection  care  should  be  taken  to  avoid  injuring  blood-vessels 
high  in  the  flap  by  turning  the  edge  of  the  knife  to  the  bone. 

12.    Disarticulation  at  the  ankle-joint  with  a  heel-flap'  has 
justly  been  regarded  as  one  of  the  greatest  iinproveinents  in  amputa- 
tion of   modern    limes.*     Not  only  is  the 
mortality  of  this  operation  very  small,  but 
when  com|)ared   with   the  stmnps  made  at 
any  other  point  of  the   foot,  or  leg,  those 
made  at  the  ankle-joint  have 
proven    eminently    superior 
and    gratifying  to   the    pa- 
tient ;   they    have  been  less 
sui)jeet    to   those   untoward 
eomplieations  and  sequela;, 
as  uleer.s,  congestions,    ne- 
crosis, and  chronic  tender- 
ness, which  impair  subsequent  usefulness  with  appropriate  and  well 
adapted  reparative  apparatus.^ 

The  broad  articular  surface  of  the  lower  extremity  of  the  tibia  with  its  inter- 
nal projection,  the  internal  malleolus,  and  the  large  projecting  extremitv  of  the 
fibula,  the  external  malleolus,  form  a  mortise  to  which  the  lateral  and  upper 
surfaces  of  the  astragalus  are  so  accurately  adapted  that  there  can  be  no  lateral 

1  L.  Verneuil.  2  E.  N(^laton.  3  j.  gyme.  *  Sir  W.  Fergusson. 

6  E.  D.  Hudson. 


Fig.  67-t. 


622 


0  PERA  TI VE  S  UR  GER  Y. 


Fig.  675. 


motion,  and  disarticulation  can  only  be  accomplished  when  the  foot  is  firmly- 
extended  and  the  knife  penetrates  tiie  anterior  part  of  the  articulation. 

Proceed  as  follows :  place  the  foot  at  a  right  angle  to  the  leg ;  en- 
ter the  knife  at  the  point  of  the  external  malleolus,  and  carry  it  di- 
rectly across  the  sole  of  the  foot  (Fig  674)  to  a  point  opposite,  or  six 
lines  below  the  internal  malleolus  (Fig.  6/5)  the  posterior  tibial  ar- 
tery divides  beneath  the  inteinal  annular  lig- 
ament into  the  internal  and  external  plantar 
arteries,  and  if  the  incision  extends  to  the 
point  of  the  internal  malleolus  the  vessel  may 
be  divided;  1  join  the  two 
extremities  of  this  incision 
by  an  anterior  incision  in  a 
direct  line  over  the  instep, 
so  that  the  cicatrix  may 
come  well  in  front  ^  (Figs. 
674,  675).  In  dissecting 
the    posterior    flap,    place 

the  fingers  of  the  left  hand  upon  the  heel,  while  the  thumb  rests 
upon  the  edge  of  the  integuments,  and  then  cut  between  the  nail  of 
the  thumb  and  the  tuberosity  of  the  os  calcis,  so  as  to  avoid  lacerating 
the  soft  parts,  which  at  the  same  time  are  gently  but  steadily  pressed 
back  until  the  tendo-achillis  is  exposed  and  di- 
vided. Disarticulate  the  foot  (Fig.  676),  and  saw 
off  the  malleoli  obliquely ;  leave  the  articular 
extremity  of  the  tibia  uninjured, 
for  it  is  better  not  to  interfere 
with  the  bone  if  it  is  healthy.^ 

There  are  many  methods  of  modify- 
ing the  construction  of  flaps  to  cover 
the  ends  of  the  tibia  and  fibula,  adapted 
to  the  various  forms  of  injury  of  the 
soft  parts;  all  coverings,  whether  from 
the  sole,  the  lateral  surfaces,  or  from 
the  dorsum  of  the  foot,  are  useful,  and 
should  be  preserved  for  that  purpose 
when  the  heel-flap  is  warning.  The  following  ex- 
amples illustrate  other  forms  of  flap:  — 

In  tlie  first  example  3  enter  a  knife  in  the  me- 
sial line  of  the  posterior  aspect  of  the  ankle,  on  a 
level  with  the  articulation,  carry  it  downwards  ob- 
liquely across  the  tendo-achillis  towards  the  external 
border  of  the  plantar  aspect  of  the  heel,  along  which 
it  is  continued  in  a  semilunar  direction;  curve  the 
incision  across  the  sole  of  the  foot,  and  terminate  it  on  the  inner  side  of  the  ten- 


FiG.  676. 


1  J.  A.  AVveth. 


2  McLeod. 


s  Mackenzie. 


AMPUTATION. 


G23 


don  of  the  tibialis  auticiis,  about  an  inch  in  front  of  the  inner  malleohis;  can-y 
the  second  incision  across  the  outer  aspect  of  the  aniile  in  a  scniiltniar  direction, 

between  the  extremities 
of  I  lie  (irst  incisions,  the 
convexity  of  the  incision 
downwards  (Fifj.  677), 
and  passiiif^  half  an  inch 
briow  the  external  mal- 
leolus. 

Or,  I  make  an  incision 
from  till'  junction  of  the 
Fig.  677.  tendo-achillis    with    the 

OS  calcis  around  the  ex- 
ternal surface  of  the  foot,  immediately  below  the  external  miillcohis,  then  carry 
it  inwards  towards  the  internal  border,  curve  forwards  and  al)()ut  an  inch  in 

front  of  the  ankle-joint 
(Fig.  678);  then  pass 
along  the  internal  border 
of  the  foot  to  the  point  of 
departure.  The  stump 
(Fig.  67!i)  is  very  useful. 
Fig.  678.  C'S"   >niike    two    horizon- 

tal incisi(ins,  commencing 
at  the  insertion  of  the  tendo-achillis  and  meeting  a  little  behind 
the  commissure  of  the  toes.  Or,^  make  an  incision  comprising 
the  semi-circumference  of  the  anterior  part  of  the  foot,  about 

three  fingers'  bi'eadth  in 
front  of  the  malleoli,  then 
from  the  external  extremity  of  the  wound 
carry  it  iiorizontally  around  under  the  ex- 
ternal uialleolus  to  the  internal  border  of 
the  tendo-achillis,  which  divide;  disartic- 
ulate, and  make  a  quadrilateral  flap  from 
the  internal  and  plantar  part  of  the  heel. 

1 .1.    Osteoplastic     amputation 
of  tibia*  proviilt's  a  c-ovciiii;;  of  the 
^"     stump   consisting    of    the    postefior 
pai't  of  the  OS  calcis,  with  the  integ- 
ument of  the  hri'l.     The  results  are  favor- 
able, l)tu  the  a<Mitional  length  of  limb  is  not 
desirable  for  an  artifuial  limb.^    Commence 
the  incision  close  in  front  of  the  outer  mal- 
leolus, carry  it  vertically  downwards  to  the 
sole  of  the  foot  (Fig.  674),  then  transverse- 
ly across  the  sole,  and  lastly  obliquely  up- 
wards to  the  inner  malleolus;  terminate  it  a 
couple    of    lines   anterior   to  the   malleolus 
(Fig.  C75);  divide  all  the  soft  parts  at  once  quite  down  to  the  os 

1  J.  Roux.       2  Baudens.       3  c.  Sedillot.       ■»  Pirogoff.       «  E.  D.  Hudson. 


679. 


Fig.  680. 


G24 


OPERA  Tl  VE  S  UR  GER  Y. 


calcis;  now  connect  the  outer  and  inner  extremity  of  this  first  incis- 
ion by  a  second  semilunar  incision,  the  convexity  of  which  looks  for- 
ward, carried  a  few  lines  anterior  to  the  tibio-tarsal  articulation;  cut 
throuiih  all  the  soft  parts  at  once  down  to  the  bones,  and  then  pro- 
ceed to  open  the  joint  from  the  front,  cutting  through  the  lateral  lig- 
aments, and  thus  exarticulate  the  head  of  the  astragalus  (Fig.  680) ; 
now  place  a  small  narrow  amputation  saw  obliquely  upon  the  os  cal- 
cis behind  the  astragalus,  and  saw  thi-ough  the  bone,  in  the  line  c 
d  (Fig.  681.)  Section  has  been  made  also  in  the  lines  a  e  and  b  f, 
but  the  stump  is  not  as  well  formed.  Saw  carefully,  or  the  anterior 
surface  of  the  tendo-achillis,  which  is  only  covered  by  a  layer  of  fat 
and  a  thin  fibrous  slieath,  may  be  injured:  raise  the  short  anterior 
flap  from  the  two  malleoli,  and  make  a  section  of  the  tibia  and  fibula 
just  above  the  articular  surfaces  ;  turn  this  flap  forwards,  and  bring 
the  cut  surface  of  the  os  calcis  in  apposition  with  the  cut  surface  of 
the  tibia;  the  tendons  must  not  be  cut  off  too  near  the  point  where 
their  synovial  sheaths  are  cut  through  ;  if  cut  too  short  they  conceal 
themselves  in  the  fibrous  canal,  or,  when  the  ,//,  „ 

limb   is    moved,    slip   upwards    out    of   their  /  ,•' 

sheaths.  /    / 

14.  Supra-malleolar  amputation  should 
always  be  preferred  to  any 
operation  at  a  higher  point, 
and  the  flap  should  be 
taken  from  the  firmest  tissue 
accessible.  The  following 
method  gives  a  good  stump: 
Make  an  incision  from  the 
base  of  the  external  malleo- 
lus, posteriorly,  around  the  -•'  .  ' 
external  surface  of  the  foot  ''    «  f 

immediately  below  the  mal-  Fig.  681. 

leolus,  and  inwards   towards  the  internal  border, 
but  curved  forwards  to  a  point  an  inch  in  front  of 
the  ankle-joint  (Fig.  682)  ;  make  a  similar  incision 
on  the  internal  surface  and  unite  the  two  behind 
by  a  transverse  incision,  having  a  slight  convexity 
downwards;  separate  the  soft  parts  from  the  bones, 
and  saw  the  tibia   and  fibula  at  the  base  of 
the  malleoli,  about  an  inch  above  the  articu- 
lar surface. 

15.  The    leg   amputation    involves   new 

and  most  important  principles  both  in  opera- 

FiG.  682.  tive  and  mechanical  surgery.     At  no  other 


AMPUTATION.  625 

point  is  it  more  necessary  to  secure  a  sound  and  useful  stump  than  in 
tliis  part.  This  is  due  to  the  incessant  use  to  which  it  must  be  ap- 
phed,  anil  its  exposure  to  injury.  But  it  presents  intrinsic  dillicuUies 
in  the  application  of  tlie  ordinary  nietlioiis  of  ainj)utation.  This  is 
apparent  in  the  cU'velopnient  of  the  inuseh-s  of  tlie  calf,  the  tapering 
form  of  the  lower  portion,  and  the  suljcutaneous  position  of  the  tibia. 
The  circular  flaj)  cannot  be  retracted  without  dividiiiLC  it  longitudi- 
nally ;  the  single  posterior  flap  is  of  immense  size,  and  is  counter- 
acted only  by  the  integument  of  the  anterior  part  of  the  leg  ;  the 
double  flap  gives  a  great  ine([uality  of  fl;ips;  the  single  external  flap 
leaves  the  crest  of  the  tibia  but  slightly  covered.  The  results  of 
amputation  of  the  leg  have,  in  consetpience  of  these  conditions,  been 
more  unsatisfactory  than  at  any  other  point.  Necrosis  of  the  tibia, 
conical  stumps,  ulcerated  coverings,  and  tender  cicatrices  have  been 
the  rule,  when  the  old  methods  have  been  preferred.  But  bilateral 
flaps  of  the  soft  parts  and  periosteal  coverings  of  the  tibia  give  a 
firm,  compact,  and  enduring  stump. 

Sufficient  data  have  now  been  accmniilated  to  establisli  tlie  comparative  anil 
practical  advantages  of  tliis  nieihod.  The  largest  experience  in  tlie  critical 
examination  of  stumps  for  the  purpose  of  applying  compensative  apparatus, 
has  led  to  the  conclusions  1  that  the  bilateral  method  gives:  (1.)  Little  liability  to 
exfoliation,  necrosis,  osteo-m velitis,  abscesses,  etc.  (2. )  Healthy  tone,  circulation, 
quality,  and  capacitv  to  the  stump,  with  the  least  amount  of  muscular  retrac- 
tion and  displacement  of  covering  tissues.  (-3.)  The  terminal  axis  of  the  stump 
constitutes  a  much  better  basis  of  support  as  conditions  may  exist ;  and  the  lev- 
erage retained,  be  it  long  or  short,  affords  a  most  important  advantage  over 
every  other  method,  both  as  regards  immediate  success,  and  the  ultimate  supe- 
rior usefulness  of  the  stump.     The  most  important  immediate  advantages  are 

(1)  a  periosteal  covering  of  the  cut  end  of  the  bone  wliicli  aids  in  preventing 
necrosis  and  osteo-myelitis,  and  insures  against  an  adherent  cicatrix  of  the  skin; 

(2)  ample  and  well  nourished  flaps;  (.3)  complete  drainage. 

The  jilace  of  division  of  the  bone  may  be  at  any  point,  but  at  the 
lower  part  of  the  leg  the  commencement  of  the  calf  is  most  favor- 
able for  a  symmetrical  stump,  and  at  the  upper  part,  a  point  two 
inches  below  the  tubercle  of  the  patella,  which  permits  the  knee  to 
be  bent,  and  brings  the  support  upon  the  comlyles  of  the  femur. 
An  amputation  at  the  latter  point  is  indicated  whenever  the  leg  is 
permanently  lle.xed,  either  at  a  right  or  at  an  acute  angle  with  the 
thigh.  If  the  amputation  must  be  very  close  to  the  joint,  disar- 
ticulation should  be  preferred,  for  the  risk  to  the  patient  of  the 
knee-joint  amputation  is  no  greater  than  of  an  amputation  of  the 
extreme  upper  third  of  the  leg,  while  its  practical  benefits  are 
much  superior,  as  confirmed  by  experience.^  The  bilateral  flap  here 
recommended  should  be  made  as  follows  :  Commence  an  incision 
with  a  large  scalpel  in  the  centre  of  the  anterior  surface  (Fig.  Gb3) 

i  E.  D.  Hudson. 

40 


626 


OPERATIVE  SURGERY. 


and  carry  it  downwards  along  the  siile  of  the  leg  so  as  to  make  a 
slightly  curved  flap  with  its  convexity  below ;  when  the  incision 
passes  over  the  prominent  part  of  the  leg  towards  the  posterior  sur- 
face, incline  it  upwards  until  the  middle  of  the  linib  is  reached,  where 
it  should  be  continued  directly  up  to  the  point  at  which  the  bone  is 
to  be  divided;  make  a  similar  incision  on  the  opposite  side;  these 
lateral  flaps  should  consist  of  the  skin  and  superficial  fascia ;  dissect 


Fig.  683. 

them  upward  to  the  extent  of  one  inch  in  the  leg  and  two  inches  in 
the  thigh;  now  make  a  circular  division  of  the  muscles  to  the  bone 
with  a  long  knife  ;  saw  the  bone  or  bones  at  this  point,  and  direct  an 
assistant  to  seize  and  hold  the  extremity  firm  with  strong  forceps 
(Fig.  618)  ;  with  the  periosteal  knife,  or  the  thumb  nails,  which  are 
equally  efficient,  raise  the  periosteum  from  the  tibia  to  the  point 
where  the  latter  is  to  be  cut;  divide  the  bone  at  the  base  of  the 
periosteal  flap.  The  periosteum  must  be  cut  at  its  attachments  to 
the  bone  and  should  be  raised  only  from  the  tibia,  the  fibula  being 
first  exsected.     The  covering  thus  prepared  has  the  integument  ex- 

ternall}-,  the  perios- 
teum internally,  Avhile 
the  intervening  tis- 
sues, muscles,  vessels, 
nerves,  have  not  been 
disturbed  in  the  dis- 
section ;  the  perios- 
teal flap  falls  like  a 

,^         %  — -WIT—       hood  over  the  end  of 

the  bone  (Fig.  684), 
the  skin  flaps  lie  in 
Fig.  684.  contact  without  ten- 

sion, the  drainage  is  direct  from  the  angle  of  the  wound  beneath. 
AVhen  cicatrization  is  complete,  the  cicatrix  lies  posterior  to  the  end 
of  the  stuuip;  the  cushion  is  freely  movable,  and  the  bone  does  not 
undergo  the  usual  amount  of  atrophy. 

16.  The  knee  joint  amputation  is  much  preferable  to  amputa- 


AMPUTATION. 


027 


tiiin  throuL^h  the  tlii'_'li;  it  is  rjuirkcr,  easii-r.  requires  simpler  instru- 
ments, antl  is  atteii(ie(l  with  less  blteclin.i;  there  is  less  shock,  less 
(lanj^er  of  septicieiuia  and  osleo-niyelitis  as  the  bone  remains  sealed; 
the  internments  [)reserved  are,  as  a  rule,  better  adapted  to  sustain 
pressure;  there  is  less  risk  of  injury  to  (laps  from  a  ruu^h  sawn  bone; 
less  retraction  of  muscles;  the  sustaining  [)ower  is  more  quickly  ac- 
quired; the  point  of  su[)port  is  broader  and  better  fitted  for  pressure; 
from  large  anastomoses  about  the  joint,  the  blood  supply  is  more 
quickly  established;  the  redundant  size  of  the  articular  head  of  the 
femur  in  time  disappears.^ 

Tlie  line  of  the  articulation  lies  internally  nine  lines  above  the  prominence  of 
the  tibia;  the  lower  border  of  the  patella  is  on  a  line  with  the  articulation,  and 
externally  it  is  nine  lines  below  the  prominence  of  the  external  condyle. 

There  are  many  methods  of  operating,  but  the  bilateral  flap 
method  is  to  be  preferred  for  the  general  reasons  given  ;  the  joint 
surface  of  the  bone  should  not  be  disturbed  unless  diseased,  and  the 
patella  may  be  left  in  its  place,  though  it  is  of  no  value  to  the  stump. 
Operate  as  follows:  Select  a  large  scalpel,  ami  commence  an  in- 
cision about  one  inch  below  the  tubercle  of  the  tibia,  and  cut  to  the 
bone;  carry  it  downward  and  forward  beyond  the  curve  of  the  side 
of  the  leg,  thence  inwards  and  backwards  to  the  middle  of  the  lew, 
thence  upwards  to  the  middle  of  the  popliteal  space  ;  repeat  this  in- 
cision upon  the  opposite  side ;  raise  the  flap,  consisting  of  ail  the  tis- 
sues down  to  the  bone,  until  the  articulation  is  reached,  divide  the 
lateral  ligaments,  enter  the  joint,  and  sever  its  connections  internallv 
ainl  externally. 

Care  should  be  taken  that  the  incisions  incline  moderately  forwards,  down  to 
the  curve  of  the  side  of  the  leg,  to  secure 
ample  covering  for  the  condyles,  and  that 
upon  the  internal  aspect  it  should  have  ad- 
ditional fullness  for  the  purpose  of  insur- 
ing sufficient  flap  for  the  internal  condyle, 
which  is  longer  and  larger  than  the  exter- 
nal. 

The  flaps  completely  cover  the 
condyles  (Fig.  685),  and  are  readily 
approximated,  leaving  ample  space 
for  direct  drainage  at  the  uj)per 
angle  of  the  wouml;  a  drain  tube 
may  be  inserted,  if  necessary;  the 
flaps  are  well  nourished  and  union  takes  place  rapidly,  giving  a  well- 
rounded  stump  with  the  cicatrix  sunk  in  the  inter-condyloid  fossa 
(Fig.  G.S4). 

The  practice  of  dividing  the  condyles  cannot  be  sustained  by  any  rational  hy- 
pothesis, nor  practiced  on  any  scientific  principles;  except  disease  or  injury  of 

1  McLeod. 


Fig.  685. 


628  OPERATIVE  SURGERY. 

the  condyles  compel  their  excision,  their  osseous  covering  and  cartilage  invest- 
ments should  be  kept  inviolate  from  knife  and  saw,  for,  as  constituted,  they  are 
the  strongest,  most  tolerant,  and  important  supports  in  the  entire  body;  the  in- 
ter-condyloid  fossa  is  readily  tilled  with  a  neatly-shaped  elastic  pad,  of  wool 
felt,  even  with  the  convexity  of  the  condyles,  and  made  to  extend  over  tlieni 
for  a  cushion,  in  the  adaptation  of  prothetic  apparatus.!  Kqually  reprehensible 
is  the  method  of  placing  the  patella  over  the  fossa  with  a  view  to  making  that 
a  point  of  support,  and  also  of  sawing  off  the  condvles  and  applying  the  patella 
to  the  cut  surface;  these  and  other  ingenious  experiments  are  of  no  practical 
value. 1 

17.  The  thigh  is  composed  principally  of  muscular  structure,  which 
surrounds  the  femur  in  two  distinct  layers,  the  superficial  and  deep; 
the  superficial  muscles  all  spring  from  the  pelvis  and  go  to  the  leg, 
and  the  lower  they  are  cut  the  more  they  retract  and  vice  versa. 

It  results  that  nearly  the  same  length  of  soft  part  cover  the  stump  at  all 
points;  above,  on  account  of  the  size  of  the  wound;  below,  to  make  up  for  the 
increased  muscular  retraction;  the  posterior  part  of  the  femur  being  almost  un- 
covered bv  deep  muscles,  retraction  is  stronger  there  than  on  the  other  sides,  the 
more  so,  as  the  slightly  flexed  position  of  the  thigh,  by  stretching  the  posterior 
muscles,  favors  still  more  their  retraction,  and  leaves  them,  when  cut,  of  less 
real  length  than  the  others;  the  same  thing  takes  place,  but  to  a  less  degree, 
on  the  inside,  compared  with  the  outside,  the  latter  only  offering  muscles  ad- 
herent to  the  bone,  and  the  muscles  on  the  inside  being  also  extended  by  abduc- 
tion ;  on  this  account,  after  circular  amputations,  the  cicatrix  is  almost  constantly 
behind  and  inside.- 

Observation  and  experience  teach  that  amputations  of  the  thigh, 
as  ordinarily  performed,  and  idtiniately  treated  with  prothetic  appar- 
atus, are  unnecessarily  disabling  ;  but  with  the  bilateral  flap  ami  peri- 
osteal reserve,  and  as  full  length  of  the  femur  for  leverage  as  the 
injury  or  disease  will  safely  allow,  a  quality  and  capacity  of  stump 
may  be  obtained,  which,  with  appropriate,  well  adapted  apparatus, 
will  assure  the  patient  a  firm  basis  of  support  on  a  line  with  the  axis 
of  the  thigh;  ample  leverage,  and  adequate  motor  power,  enables 
him  to  balance  his  weight  exclusively  on  his  artificial  limb,  and  to 
walk  without  a  cane,  with  ease  and  gracefulness.^  If  such  an  op- 
eration should  prove  a  secondary  success,  and  ultimately  require  par- 
tial or  entire  peripheral  support  in  the  a<laptation  of  prothetic  ap- 
paratus, nothing  will  have  been  lost,  Avhen  compared  with  the  past 
amputations  and  their  results,  and,  eventually,  much  may  be  gained, 
as  has  occurred  in  many  cases  of  the  ordinary  modes  of  operation ; 
as  a  rule,  the  most  perfect  success  may  reasonably  be  expected  of 
the  bilateral  variety  of  operation,  and  the  pleasing  and  profitable 
results  experienced,  in  both  civil  and  military  surgery,  afford  guar- 
antees to  the  mutilated  of  the  greatest  possible  amount  of  benefit, 
with  appropriate  apparatus.^  The  method  of  procedure  requires  the 
same  incision  as  the  operation  on  the  leg  already  detailed  (Fig.  683). 
1  E.  D.  Hudson.  2  j.  p.  Malgaigne. 


AMPUTATION.  629 

(1.)  Ijateral  fl^ps  are  nuule  as  follows:  Introduce  the  knife  in  the  centre  of 
the  liml),  liircctly  dnwii  to  the  lionc,  on  one  side  of  which  it  is  parsed  to  the  op- 
posite side  of  the  liiiilj  and  the  flap  is  then  formed  (Fij;.  G14).  then  introduce  the 
knife  and  make  a  tlaj)  on  the  opposite  side;  strongly  retract  tlie  tiups  and  saw 
the  hone  at  the  hii;iiest  point. 

(2)  Antero-posterior  flaps  are  made  thus:  Standinj;  at  the  ri!;ht  side  of 
the  limb,  j^rasp  the  soft  parts  and  brinf?  tlieni  forward;  transfix  the  limb,  the 
knife  grazing;  the  upper  surface  of  the  bone  and  make  an  anterior  flap  (Fig.  C14); 
reintroduce  the  knife  and,  passing  it  under  the  bune,  make  a  posterior  flap  longer 
than  the  anterior  (Fig  tjl4).  to  compensate  for  the  greater  retraction  ;  complete  the 
operation,  as  in  the  lateral  flap  method.  Another  method  is  as  follows  :  stand- 
ing at  the  right  side  of  the  limb,  grasp  the  thigh  with  the  left  hand,  placing  the 
fingers  and  thumb  on  opposite  points,  apply  the  heel  of  a  lung  amputating 
knife  on  the  further  side  of  the  limb  at  the  ends  of  the  fingers,  and  drawing  it 
in  a  semi-circular  directi(Mi  over  the  limb  to  the  end  of  the  thumb,  tlividing  by 
this  single  sweep  all  the  soft  parts  down  to  the  bone;  without  removing  the 
knife,  withdraw  it  sufficiently  to  enter  the  point  at  the  angle  of  the  wound,  and 
transli.K  the  limb,  passing  under  the  bone  to  the  angle  of  the  wouiul  on  the 
opposite  side ;  cut  a  Ilup  of  the  requisite  length  from  the  posterior  part  of  the 
thigh. 

18.  The  hip-joint  is  formed  by  the  head  of  the  femur  and  the  ace- 
tabulum, into  whicli  it  is  reeeived:  its  li<faments  are  the  rouiiil  liga- 
ment, which  attaches  the  head  of  the  bone  to  the  bottom  of  the  cav- 
ity, and  the  ca|)sular  li'^ament  surrounding  the  joint;  it  is  deeply 
situated  under  thick  and  powerful  muscles,  and  can  be  felt  only  on 
the  anterior  part;  it  must  be  recoUecteil  that  the  plane  of  the  margin 
of  the  acetabulum  inclines  downwards  and  forwards,  projecting  more 
posteriorly  than  anteriorly:  the  arteries  are  the  femoral,  the  obtu- 
rator, the  ischiatic,  and  external  and  internal  circumlKx.  The  fol- 
lowing are  anatomical  guides  to  the  joint:  — 

(1.)  The  anterior  inferior  spinous  process  of  the  ilium  is  three  quarters  of  an 
inch  above  the  superior  margin  of  the  acetabidum;  the  anterior  superior  spi- 
nous process  is  about  an  inch  and  three  quarters  above  the  .same  point,  and 
three  quarters  of  an  inch  to  its  outer  side.  (2.)  The  anterior  border  of  the 
acetabulmn  is  from  an  inch  to  an  inch  and  a  quarter  to  the  outside  of  the 
spine  of  the  pubes.  (.3.)  The  axis  of  the  horizontal  ramus  of  the  pubes,  ex- 
tended by  an  imaginary  line,  crosses  the  acetabulum  at  the  junction  of  its  su- 
perior with  its  middle  third.  (4.)  The  superior  b(uder  of  the  trochanter  major 
is  on  a  level  with  the  upper  third  of  the  cavity  of  the  joint. 

Amputation  may  be  performed  by  the  single  flap,  anterior  or  in- 
ternal; the  double  flap,  lateral,  or  antero-posterior;  the  oval;  and 
the  circular.  These  different  mt^thods  have  been  almost  indefinitely 
modified.  HiPmorrhage  shoubl  be  i)revented  by  the  application  of  a 
tonrnicpiet*  or  a  compress ^  to  the  abdominal  aorta.  The  common 
iliac  may  be  compressed  through  the  rectum  by  means  of  a  sh.ift 
having  a  curved  extremity,  which  m;iy  be  hooked  over  the  brim  of 
the  pelvis.*     The  shock  due  to  the  loss  of  the  blood  in  the  liml)  may 

1  J.  Lister.  =*  J.  Spence.  *  It-  l>avy. 


630 


OPERATIVE  SURGERY. 


be  prevented  by  first  applying  the  elastic  bandapje  to  the  limb,  and 
fixing  the  tube  just  below  the  line  of  incision. ^  The  operation  should 
always  be  performed  with  antiseptic  precautions,  and  provision  for 
thorough  drainage  should  be  made. 

1.  The  single  flap  method  admits  of  very  rapid  performance 2  (Fig.  686). 
The  following  are  tlie  several  step.s  :  The  patient  lying  upon  the  edge  of  the 
table,  the  hip  projecting,  the  arterv  is  compressed  upon  the  horizontal  branch  of 

the  pubes ;  the  operator  then  takes  a  po.silion 
on  the  outside  of  tlie  limb  (the  left),  which 
is  separated  from  the  other  and  slightly 
^iji  tJexed  on  the  pelvis,  and  raising  the  soft 
''jL  parts,  which  cover  the  anterior  face  of  the 
limb,  enters  a  very  long  double-bladed 
knife  midway  between  the  great  trochanter 
and  the  anterior  superior  spine  of  the  ilium, 
direcling  it  at  first  slightly  from  below  up- 
wards, and  from  without  inwards,  a,  c,  so 
as  to  reach  the  head  of  the  femur,  and  open 
the  capsule  of  the  joint;  he  now  elevates 
tlie  handle,  and  carries  the  knife  in  the 
direction  a,  b,  the  point  emerging  about 
an  inch  below  and  in  front  of  the  tuberos- 
ity of  the  ischium;  the  knife  is  then  car- 
ried downwards  along  the  anterior  surface 
of  the  bone,  and  a  large  semilunar  flap  is 
made,  e.Ktending  nearly  half  tiie  length  of 
the  thigh,  or  six  inches;  care  should  be  taken  that  the  flap  is  as  long  on  the 
inside  as  on  the  outside;  an  assistant  raises  the  flap,  o,  e,  at  the  same  time  com- 
pressing the  artery  which  it  contains;  the  knife  is  now  applied  to  the  capsule, 
which  is  divided  close  to  the  acetabulum,  as  if  about  to  cut  across  the  middle 
of  the  head  of  the  femur,  D,  and  at  least  half  of  its 
circumference;  the  limb  is  then  abducted  to  luxate 
the  head  of  the  bone,  the  knife  passed  beiiind  it,  and 
the  soft  parts  on  the  posterior  portion  of  the  limb 
vided  as  in  the  circular  o|)eration. 

2.  Double  antero-posterior 
flaps  are  made  thus  3  (Fig.  687) : 
Standing  on  the  outside  of  the 
liuib,  insert  the  point  of  a  long 
catling  about  midway  between  the 
anterior  superior  spinous  process 
of  the  ilium  and  trochanter  major, 
keeping  it  rather  nearer  the  former 
than  the  latter;  then  run  it  across 
the  fore  part  of  the  neck  of  the 
bone,  and  push  it  through  tiie  skin 
on  the  opposite  side,  about  two  or 
three  inches  from  the  anus;  next, 

carry  it  downwards  and  forwards,  so  as  to  cut  a  flap  from  the  anterior  aspect  oi: 
the  thigh,  about  four  to  si.x  inches  in  lengtli.     When  the   blade  is  entered,  the 

1  E.  Mason.  2  Malgaigne;  Gudrln.  3  Sir  W.  Fergusson. 


AMPUTATION. 


031 


limb  should  he  held  up,  and  even  slif^htly  bent  at  the  joint;  the  instrument  will 
then  pass  alon?  more  readily  than  if  all  the  textures  were  thrown  on  the  >tretch; 
moreover,  there  Ts  preater  certainty  of  passiiijj  it  behind  the  main  vessels,  and 
even  dividing  some  of  the  fibres,  if  not  the  whole,  of  the  iliacus  internus  and 
psoas  museles.  As  the  knife  is  carried  downwards,  the  assistant,  who  stands 
behind  the  operator,  should  slip  his  tinj^ers  into  the  wound  anil  carry  then)  suf- 
ficiently far  across  to  enable  him  to  grasp  the  femoral  artery  between  tlu-in  and 
the  thumb:  this  he  may  do  from  the  inside  or  outside  at  will,  and  with  the  right 
or  left  hand,  as  may  be  most  convenient,  the  same  grasp  enabling  him  to  raise 
the  Hap  as  soon  as  it  is  completed.  The  tlap  being  raised,  the  point  of  the 
knife  should  then  be  struck  against  the  head  of  the  bone,  so  as  to  divide  the 
anterior  part  of  the  capsular  ligament  and  any  textures  in  this  situation  which 
may  not  have  been  included  in  the  tlap.  To  facilitate  this  part  of  the  opera- 
tion, the  knee  should  be  forcibly  depressed  by  the  a.ssistant  who  holds  it;  the 
head  of  the  bone  will  thus  be  caused  to  start  from  its  socket,  and,  if  the  round 
ligament  is  not  ruptured  by  the  force,  a  slight  touch  with  the  edge  of  the  knife 
will  cause  it  to  give  way.  At  this  period,  depression  being  no  longer  required, 
the  assistant  should  bring  the  head  of  the  femur  a  little  forwards,  to  allow  the 
knife  to  be  slipped  over  and  behind  it,  and  when  it  is  in  the  position  represent- 
ed in  the  design,  it  should  then  be  carried  downwards  and  backwards,  so  as  to 
form  a  flap  somewhat  longer  than  that  in  front,  the  last  cut  completing  the  sep- 
aration of  the  limb. 

3.  Double  lateral  flaps'  (Fig.  G88)  are  made  as  fidlows :  The  patient  must 
be  laid  n\\i\\\  his  back  with  the  tuberosities  of  the  ischia  projecting  slightly  be- 
yond the  edge  of  the  bed,  and  the  limb  held  in  a  position  between  abduction  and 
adduction.  Then,  having  determined  by  the 
anatomical  rules  laid  dr)wn  the  anterior  and 
external  side  of  the  articulation,  the  operator 
holding  perpendicularly  a  long  double-edged 
knife  introduces  it  at  this  point  with  its 
lower  edge  looking  downwards  towards  the 
great  trochanter.  As  the  point  of  the  knife 
enters  it  should  be  carried  around  the  head 
of  the  femur,  on  its  outer  side,  whilst  its 
handle  is  inclined  upwards  and  outwards, 
and  pushed  steadily  on  in  this  direction  so 
that  it  perforates  the  inteeumentsa  few  lines 
below  the  tuberosity  of  the  ischium.  While 
this  is  being  done  an  assistatit  grasps  the 
tissues  over  the  trochanter  and  carries  them 
outwards,  in  order  to  assist  in  the  formation 
of  the  external  tlap,  and  the  knife  is  carried 
downwards  and  outwards  with  a  slightly 
sawing  motion,  around  the  great  trochanter,  and  along  the  femur,  cutting  out 
a  Hap  from  three  to  four  inches  in  length,  n,  b,  c.  The  first  tlap  being  thus 
made,  the  operator  grasping  the  tissues  on  the  inside  of  the  thigh  and  carrving 
them  inwards,  introduces  the  knife  below  the  head  of  the  femur,  and  on  the 
inner  side  of  its  neck,  holding  it  in  a  perpendicular  position.  As  it  enters,  the 
point  of  the  knife  should  |)ass  arnund  the  neck  of  the  femur  and  come  out  at 
the  lower  angle  of  the  wound  already  made,  without  coming  in  contact  with 
the  bones  of  the  pelvis;  it  is  then  carried  downwards  along  the   femur,  and 

1  Lisfranc's. 


Fig.  683. 


632 


OPERATIVE  SURGERY. 


avoiding  the  lesser  troclianter,  so  as  to  make  an  internal  flap  of  the  same  length 
as  the  external,  e,  f.  The  tlaps  being  drawn  aside  by  tlie  assistants,  and  the 
arteries  tied,  the  surgeon  grasps  the  femur  witli  his  left  hand,  and,  holding  the 
knife  perpendicularly  on  the  inner  side  of  the  head  of  the  bone,  cuts  the  cap- 
sular ligament  without  attempting  to  penetrate  the  articulation.  The  joint 
being  opened,  the  disarticulation  is  concluded  by  cutting  the  fibrous  and  mus- 
cular tissues  which  remain. 

Care  should  be  taken  that  the  incisions  incline  moderately  forwards  down  to 
the  curve  of  the  side  of  the  leg,  to  secure  ample  covering  for  the  condyles,  and 
that  upon  the  internal  aspect  it  should  have  additional  fullness  for  the  purpose 
of  giving  sutBcient  flap  for  the  internal  condyle,  which  is  longer  and  larger  than 
the  external. 

4.  Double  Flaps,  long  anterior  and  short  posterior,  give  good  results  i 
The  surgeon  enters  the  point  of  the  knife  between  the  spine  of  the  ilium  and  the 
trochanter  major,  and  carries  it  across  the  thigh,  as  near  as  may  be  to  the  head 
and  neck  of  the  femur,  until  the  point  appears  on  the  inside  near  the  scrotum, 
which  should  have  been  previously  drawn  away.  The  knife  is  to  cut  slowly 
downwards,  to  make  a  flap,  under  which  an  assistant  inserts  his  four  fingers,  in 
order  to  be  able  to  grasp  the  flap  and  aid  in  compressing  the  prnicipal  artery, 
as  the  operator  completes  the  flap,  which  should  be  a  large  one.  The  assistant 
holding  up  the  flap,  the  surgeon  cuts  the  attachment  of  the  gluteus  medius  mus- 
cle from  the  upper  edge  of  the  trochanter,  if  it  has  not  been  alread}'  done,  opens 
the  capsular  ligament  of  the  joint,  and  divides  the  ligamentum  teres.  The  head 
of  the  bone  can  then  be  readily  withdrawn  from  the  acetabulum.  The  knife, 
being  placed  behind  the  head  of  the  bone  and  the  trochanter,  should  be  carried 
obliquely  downwards  and  backwards,  so  as  to  form  a  sliorter  flap  behind  than 
was  made  before. 

5.  The  oval  operation  is  as  follows  2  (Fig.  689) :  Standing  on  the  inside,  com- 
mence tlie  first  incision  three  or  four  inches  directly  below  the  anterior-spinous 

a  process  of  the  ilium,  a,  carry  it  across  the 
thigh  through  the  integuments,  inwards  and 
backwards,  in  an  oblique  direction,  at  an 
equal  distance  from  the  tuberosity  of  the 
ischium  to  nearly  opposite  the  spot  where 
the  incision  commenced,  c;  carry  it  up- 
wards with  a  gentle  curve  behind  the  tro- 
chanter, until  it  meets  with  tlie  commence- 
ment of  the  first,  h;  retract  the  integu- 
ments, including  the  fascia;  cut  the  three 
gluteal  muscles  through  to  the  bone;  the 
knife  being  then  placed  close  to  the  re- 
tracted integuments,  cut  through  everything 
on  the  anterior  i>art  and  inside  of  the  thigh. 
The  femoral  or  other  large  artery  should 
then  be  drawn  out  by  a  tenaculum  or  spring 
forceps,  and  tied.  The  capsular  ligament 
being  well  opened,  and  the  ligamentum  teres  divided,  pass  the  knife  behind  the 
head  of  the  bone  thus  dislocated,  and  cut  its  way  out,  care  being  taken  not  to 
have  too  laige  a  quantity  of  muscle  on  the  under  part,  or  the  integuments  will 
not  cover  the  wound,  under  which  circumstances  a  sufficient  portion  of  muscular 
fibre  must  be  cut  away. 

1  C.  Heath.  2  c.  J.  Guthrie. 


Fig.  689. 


DEFORMITIES.  033 

6.  The  circular  method  has  recently  littii  preferred  to  other  methods. i  The 
first  incision  siioiild  ln'  inadc  al)ont  six  intlios  below  the  iinteriiir  superior  s[iiiie 
of  tiie  ilium;  the  skin  and  snperticial  fascia  iteing  turned  hack,  the  second  in- 
cision should  be  made  tlironi;h  the  muscles;  these  Iteiuj;  retracted,  the  next  in- 
cision may  expose  the  hone;  the  joint  is  now  opened,  the  knife  passed  behind 
tlie  head,  and  tlie  soft  parts  severed. 


CHAPTER    LIX. 

DEFOHMITIICS. 

Deformities  of  the  extremities  occur  as  congenital  and  actjuired 
conditions. 

I.    PIIAL.\NGES. 

1.  A  supernumerary  digit-  appears  in  many  forms,  and  sliould 
l)e  treated  accordiuii  to  the  pecuharitie.s.  (1.)  If  it  is  attached  loosely 
or  by  a  narrow  ])edicle,  divide  the  pedicle  close  to  its  point  of  at- 
tachment to  the  skin  so  that  no  remains  maybe  left;  haemorrhaiie 
must  be  carefidly  suppressed.  (2.)  If,  it  is  more  developed,  and  ar- 
ticulates with  the  sides  of  a  metacarpal  or  phalangeal  bone,  which 
is  common  to  it  and  another  digit,  operate  early,  atid  .so  arrange  the 
incisions  as  to  leave  as  small  a  cicatrix  as  possible.  (3.)  In  cases 
where  the  additional  digit  is  connected  to  tlie  head  of  a  phalangeal 
or  metacarpal  bone,  the  removal  is  likely  to  involve  the  opening  of 
the  joint  of  the  adjacent  phalanx;  removal  is  advisable  only  in  case 
the  additional  i)halanx  impairs  the  function  of  the  other.  (4.)  If 
the  digit  is  fully  developed,  having  its  own  [)halangeal  and  metacar- 
pal bone,  removal  is  rarely  advisable,  but  if  required,  they  must  be 
taken  away  so  as  to  leave  as  little  deformity  and  impairment  as  pos- 
sible. 

2.  The  union  of  digits,  webbed,  may  be  congenital,  when  it  is 
generally  symmetrical;  or  the  result  of  injuries  and  burns.  The  uniting 
medium  may  be  the  skin  only,  or  the  skin  and  deeper  tissues,  and 
even  the  bone.  The  two  apposing  digits  may  be  united  throughout 
their  entire  length,  or  only  in  jiart.  Webbed  toes  does  not  re(juire 
treatment.  When  the  union  is  partial,  and  does  not  involve  the 
interspace  at  the  ch'ft,  divide  the  connecting  tissue,  and  maintain 
the  fingers  ai)art,  until  cicatrization  is  complete.  When  the  union  at 
the  cleft  is  complete  there  is  great  didiculty  in  i)revenling  reunion 
after  division.  Introduce  a  seton  at  the  base  of  the  cleft*  (Fig. 
690)  and  allow  it  to  remain  until  the  opening  becomes  permanent, 
when  the  remainder  of  the  web  may  be  divided;  India-rubber  tubin'i; 
introduce<l  at  the  same  j)oiiit  and  tieil  to  a  band  around  the  wrist 
makes  a  good  seton. 

1  E.  Mason.  -  T.  Annandale.  8  j.  Lister. 


G34 


OPERATIVE  SURGERY. 


Or,  make  two  flaps  of  the  web,  anterior-and  posterior,^  but  reversed;  for  the 
posterior,  make  an   incision  along  the  dorsal  aspect  of  one  tinger  the  length  of 

the  web,  and  transverse  incisions  at 
either  extremity  to  tiie  middle  of  the 
dorsum  of  the  other  tinger;  repeat  the 
operation  on  the  palmar  surface,  but 
make  the  longitudinal  incision  along  the 
palmar  surface  of  the  finger  which  forms 
I  the  base  of  the  posterior  flap;  dissect  the 
'two  flaps  and  turn  them  back;  separate 
the  fingers  which  now  have  each  a  flap, 
one  attached  upon  the  dorsal  and  the  oth- 
er upon  the  palmar  surface;  apply  the 
flaps  to  their  respective  fingers  ;  the 
union  of  these  flaps  effectually  separates 
the  fingers.  Or,  separate  the  web  along 
one  finger,  unite  its  margins,  and  thus 
form  a  flap  for  the  opposed  digit;  close 
the  wound  left  upon  the  other  tinger  bj' 
a  piece  of  skin  transplanted  from  the 
hip,  the  hand  being  bound  to  the  part  un- 
til adhesion  has  taken  place. - 

3.  Flexion  of  the  phalangeal 
joints,  so  as  to  permanently  distort  tlio  fingers,  may  be  congenital  or 
acquired.  Wlien  the  deformity  can  be  overcome  by  division  of  con- 
tracted tendons  or  fascia,  this  operation  must  be  performed  and  suit- 
able spUnts  applied.  If,  however,  the  conditions  are  unfavorable  to 
tenotomy,  the  affected  joint  should  be  exsected.^  In  extreme  cases 
amputation  is  the  only  successful  remedy.'^ 

4.  Distortion  of  a  phalanx  may  be  caused  by  arthritis,  or,  in 
the  case  of  the  great  toe,  by  a  bunion.  The  position  in  most  cases 
may  be  properly  rectified  by  excision,^  but,  in  extreme  cases,  ampu- 
tation may  be  the  preferable  operation. 


Fig.  690. 


II.    MAL-POSITIOX  AFTER  FRACTURE. 

When  union  takes  place  with  such  distortion  as  to  impair  the  use- 
fulness of  the  limb,  the  deformity  must  be  rectified. 

1.  Extension  and  compression  maybe  made  in  recent  cases; 
immediate  straiglitening  luay  follow,  with  the  right  hand  grasping 
and  extending  the  extremity,  while,  with  the  other,  firm  compression 
is  made  upon  the  convex  portion;  to  obtain  more  gradual  results  ap- 
l)ly  a  weight  and  pulley  to  the  extremity  and  bind  a  straight  splint 
on  the  concave  side  with  as  much  tightness  as  the  ])atient  will  bear. 

2.  Refracture  must  be  effected  if  the  first  method  fail.  Proceed 
as  follows:   The  patient  being  under  an  ansesthetic,  bend  the  limb 

1  J.  K.  Rodgers.  2  15.  Brodhurst.  3  A.  C.  Post.         ■*  T.  Annandale. 

5  F.  H.  Hamilton. 


DEFORMITIES. 


r.05 


over  tlie  knee,^  or  over  the  edge  of  .a  table  or  board;  or,  tin-  liiiil) 
being  well  fixed  by  assistants,  the  wciglit  of  the  body,  or  even  uf 
two  pt-rsons,  may  be  thrown  upon  it.^  When  the  fracture  occurs,  a 
rotary  motion  should  be  given  to  the  lower  fragment.'^  ]f  these 
means  fail,  resort  may  be  had  to  the  osteoclast,  or  to  osteotomy. 
The  osteoclast  has  frequently  been  used,^  but  there  lias  been  a  lack 
of  precision  as  to  the  point  of  fracture.  This  defect  has  been  over- 
come and  a  transverse  fractun;  may  be  produced  at  any  selected 
point  with  ease,  certainty,  and  freedom  from  after-complication. 

(1.)  The  osteoclast,  as  perfected,^  consists  of  a  U-'-l'apt'tl  ''ar  of  iron  (Fig. 
691,  1,  2)  three  fourths  of  an  inch  square,  on  one  ramus  of  wliich  is  placed  a 
hard  rubber  pad  one  and  tliree 
fourths  inclies  wide,  and  curved 
to  fit  the  rounded  surface  of  the 
thigh.  Un  the  side  opposite  to 
this  pad  a  v-^'i'>P'^fl  bar  of  iron 
(3)  is  fitted  under  the  ramus,  and 
controlled  by  two  thumb-screws 
(4,  4)  which  pass  through  the 
ramus  itself  (Fig.  691).  A  strong 
piece  of  hard  wood  (5,  6)  is  used 
for  the  fracturing  lever.  At  the 
lower  end  of  the  lever  a  pad  (6), 
similar  to  the  one  just  described, 
is  firmly  fastened  and  is  intended 
to  rest  over  the  trochanter  major. 
The  pad  resting  over  the  trochan- 
ter major,  the  body  of  the  lever 
passes  under  the  V  shaped  piece, 
extends  along  the  femur  and  par- 
allel to  it,  and  has  fitted  into  it,  at 
the  distal  extremity,  female  por- 
tions of  a  screw,  through  whicli  a  threaded  rod  (12)  works  as  its  point  rests  in 
a  socket,  upon  the  outer  side  of  a  free  pad  (9,  10),  also  rublier-liued.  that  is 
placed  in  contact  with  the  distal  extremity  of  the  femur.  The  threaded  rod 
terminates  in  a  crank-like  handle  (13,  14,  15,  16).  The  instrument  is  placed 
so  as  to  avoid,  as  much  a<  possible,  injurious  ])ressure  on  the  large  vessels  and 
the  larger  messes  of  muscles.  The  regulating  screws  (4,  4)  are  then  adjusted 
until  the  three  pads  mentioned  sustain  a  uniform  and  firm  pressure,  when  i)y 
a  few  rapid  turns  of  the  crank  the  fracture  is  i)roduced  beneath  the  pad  (1). 

(2.)  Osteotomy,  section  of  bone,  though  creating  all  the  conditions  of  a  com- 
pound fracture,  has  proved  an  entirely  safe  and  successful  jirocedure  wlien  anti- 
septic precautions  are  used.  The  operation  may  be  performed  with  a  saw,  or  a 
chisel  and  mallet.  The  saw^  is  three-eighths  of  an  inch  in  width,  with  one  inch 
and  a  half  cutting  edge  at  the  end  of  a  small  shank  three  inches  in  length. 
Make  the  puncture  down  to  the  bone  with  a  long  tenotomy  knife;  divide  tlie 
muscles,  and  open  the  capsule  freely:  on  withdrawing  the  knife,  pass  the  saw 
along  the  track  made,  down  to  tlie  bone,  and  saw  through  it;  straighten  lliu 
limb  and  close   the  wound  firmly  with   suture,   or  adhesive  plaster;  apply  a 

1  S.  D.  Gross.      -  F.  C.  Skev.     »  RizEoli.      ••  C.  F.  Taylor.      5  \V.  Adams. 


Fio    691. 


636  OPERATIVE  SURGERY. 

splint  or  a  gypsum  dressing.  When  the  chisel  i  is  used,  select  a  carver's  cold 
chisel. 2  three-eighths  of  an  inch  in  width  at  the  cutting  edge,  which  is  widest, 
and  three  inches  and  a  half  long  in  tiie  shaft;  make  an  incison  by  penetration 
with  a  pointed  knife,  double-edged,  down  to  and  at  rigiit  angles  with  the  bone, 
dividing  the  periosteum;  introduce  the  chisel  b}'  the  side  of  the  knife,  and  at 
right  angles  to  the  axis  of  the  shaft  of  the  femur;  with  a  light  wooden  mallet 
drive  the  chisel  well  into  the  bone,  then  partially  withdraw,  and  again  drive 
it  onwards,  inclined  somewhat  obliquely  forwards,  and  then  backwards,  so  as 
to  divide  the  bone  in  the  rest  of  its  thickness  ;  finally,  gradually  and  carefully 
extend  the  limb,  breaking  any  small  portion  which  may  have  escaped  tiie  chisel. 
The  incision  of  the  skin  should  be  a  little  to  one  side  of  the  point  where  the 
bone  is  divided  to  render  the  deep  wound  subcutaneous.  The  wound  may  be 
closed  by  suture  or  adhesive  strip,  and  a  splint  should  be  applied,  or  gypsum 
dressing. 

III.    DISTORTIONS  OF  THE  FEET. 

Distortions  of  the  feet  may  be  due  to  spasmodic  action  of  one  class 
of  muscles,  the  antagonizing  muscles  acting  normally,  or  to  paralysis 
of  one  class,  the  opposing  muscles  being  healtby.  Careful  examina- 
tion of  each  case  will  determine  whether  spasm  or  paralysis  is  the 
cause;  but,  in  general,  congenital  cases  are  caused  by  spasm,  and 
non-congenital  by  paralysis.  The  general  rule  of  treatment  is  to  en- 
deavor to  overcome  those  deformities,  by  appliances,  which  readily 
yield  to  manipulation,  and  are  caused  by  paralysis,  and  to  divide 
contracted  tendons  in  those  which  do  not  yield  readily,  and  are 
caused  by  spasm.  The  objects  of  treatment  are  the  restoration  of 
form  and  function,  and  the  means  to  be  employed  are  physiological, 
mechanical,  and  operative. 

The  scientific  treatment  of  severe  deformities  can  only  be  accomplished  by  a 
judicious  combination  of  these  three  methods,  and  many  of  the  failures  are  due 
to  the  want  of  this  combination  of  piinciples  too  frequently  considered  antag- 
onistic to  each  other. 3 

Selecting  talipes  varus,  the  most  frequent  example  of  club-foot, 
the  rules  of  treatment  as  regards  the  adoption  of  the  several  methods 
are  as  follows:  ^  If  no  obstacle  exists  to  the  perfect  restoration  of 
form  by  gentle  application  of  force,  the  defect  may  be  remedied  by 
the  manipulations  of  the  nurse,  aided,  in  more  marked  cases,  if  nec- 
essary, by  simple  mechanical  appliances,  as  rubber  plnster,  a  boot 
with  springs.  (2.)  If  the  foot  can  be  nearly  but  not  quite  restored 
to  its  natural  form  by  the  hand,  the  heel  remaining  somewhat  ele- 
vated so  as  to  limit  or  jirevent  flexion  at  the  ankle-joint,  tenotomy  is 
justifiable,  as  it  greatly  hastens  the  cure.  (3.)  In  more  severe 
grades,  tenotomy  is  indispensably  necessary;  these  cases  are  recog- 
nized by  the  following  features,  namely,  the  foot  cannot  be  fully 
everted  or  brought  to  a  straight  line  with  the  leg  by  manij)ulation, 

1  R.  Volkman.  2  c.  F.  Maunder.  3  "W.  Adams. 


defohmities. 


C37 


and  in  the  attempt  to  effect  this  tlie  inner  malleolus  does  not  become 
prominent;  (2)  the  os  calcis  either  cannot  be  depressed  at  all,  or 
only  to  a  sli'j;ht  degree,  so  that  after  the  j)aitial  evcrsion  of  the  foot 
little  or  no  flexion  at  the  ankle-joint  can  be  obtained.* 

The  following  suminary  of  principles  of  treatment  of  congenital  clubfoot 
deserve  attention:-  (1.)  W'hetiier  tlie  case  promises  favorably  for  meciianical 
treatment  only,  or  needs,  as  the  majority  of  cases  do  nei-d,  operative  interfer- 
ence, commence  tiie  treatment  as  soon  after  birth  as  practicable.  (2.)  Kediice 
the  distortion  from  the  state  of  a  compound  one  (varus)  to  the  simpler  form 
(equinus),  by  first  curing  the  inversion  of  the  foot,  and  the  tendency  to  involu- 
tion of  the  sole.  (3.)  .\void  the  slightest  undue  pressure  upon  prominent  points 
of  the  leg  and  foot,  by  careful  padding  of  liie  hollow  parts,  and  bv  using  onlv 
gentle  pressure  with  any  bandage;  avoid  obstruction  of  the  returning  blood 
from  the  limb.  (4.)  Heniove  splint  and  bandage  daily,  practice  gentle  move- 
ments of  the  foot  in  the  desired  direction,  endeavor  to  prevent  the  part  remain- 
ing for  an  instant  unsupported  and  liable  to  fall  back  into  the  deformed  position, 
until  it  is  found  that  the  foot,  on  removal  of  the  bandage,  retains  a  perfectly 
good  position  and  flexibility.  (5.)  Never  permit  the  child  to  be  placed  on  the 
feet,  or  to  walk  until  the  form  and  movements  are  complete,  whatever  may  be 
the  age  of  the  patient.  The  only  apparatus  necessary  to  carry  out  this  treat- 
ment is  a  splint  of  tin  or  pasteboard  so  adapted  to  the  external  parts  as  to  leave 
a  space  between  the  foot  and  splint  when  bandages  are  applied,  or  rubber  plaster 
applied  to  the  anterior  part  of  the  foot,  and  passing  up  the  external  surface  of 
the  leg  to  which  it  is  fastened. 

1.  Talipes  equinus  (Fig.  692)  is  usually 
non-congenital.     Tiie  treatment  is  operative 
and  mechanical.     The  len- 
do-acbiilis     and     plantaris 
may    alone    require    divis- 
ion,   or,    in    addition,    the 
j)lantar  fascia  must  be  cut, 
as    when    the  arch  of  the  , 
foot  is  strongly  contracted  ;;^^ 
the  foot  should   usu-  "^ 
ally  be  brought  into 
))osition  at  once  and 
retained  by  splints  or 

the  gypsum  bandage.  At  the  end 
of  a  week  the  shoe  should  be  applied 
(Fig.  693). 

Its  construction  and  modes  of  action  are 
as  follows:  a  cushioned  iron  cap  to  receive 
the  heel,  the  leather  covering  of  which  i3 
carried  over  the  instep  and  ankle,  and 
fastened  by  lacing ;  elastic  tubiiig.  x,  to 
go  in  front  of  the  ankle-joint,  to  further  secure  the  heel  in  position,  and  fasteii- 


TiG.  t)'J2. 


1  W.  Adams. 


2  W.  J.  Little. 


8  G.  Tiemann  &  Co. 


638 


OPERATIVE  SURGERY. 


Fig.  695. 


ing  at  C  an  iron  hook  on  outside  of  heel  cap  ;  sole  of  shoe,  d,  cushioned,  and 
laced  securely  in  front  of  the  niedio-tarsal  articulation ;  ball  and  socket  joint,  K, 
connecting  sole  with  heel  ;  elevated  plate  of  iron,  f,  properly  cushioned,  to 
make  pressure  against  base  of  first  metatarsal  bone;  steel  bars,  G,  connecting 
the  shoe  with  strap,  ii,  to  go  around 
the  calf;  joint  K,  opposite  the  ankle; 
stationary  hooks,  l,  opposite  the  toes, 
for  attaching  the  India-rubber  mus- 
cles, M  M  M.  These  India-rubber 
tubes  have  chains  at- 
tached, and  are  for  the 
purpose  of  making 
flexion  and  eversion. 

Or,  the  following 
more  simple  appa- 
ratus may  be  used  : 
the  sole  of  the 
sti-ong  leather  shoe 
is  of  metal,  with  a 
joint  near  the 

heel,  allowing  lateral  motion  ;  a  durable  spiral 
spring,  a  (Fig.  C94),  draws  the  foot  outward 
b}-  a  constant,  elastic,  and  easy  traction; 
this  pressure  is  increased  or  decreased  at 
will,  by  fastening  the  spring  in  a  series 
of  sockets  c.  The  single  outside  upright 
steel  bar,  with  joints  at  the  ankle,  is  fas- 
tened round  the  limb  below  the  knee-joint,  and 
constructed  that  the  screw  at  the  ankle-joint  fore 
the  foot  Hat  upon  the  floor,  the  foot  in  almost  all  cas 
being  turned  under  as  indicated  (Fig.  692);  the  spii 
spring,  r/,  attached  to  a  catgut  cord  and  fastened  ne 
the  toes  upon  the  outside  of  the  foot,  elevates  t 
toes  and  stretches  the  tendo-achillis,  thus  drawing  t 
foot  to  its  natural  position. 

2.  Talipes  calcaneus  (Fig.  695)  is  both  acongei 
tal  and  non-congenital  affection.  In  congenital  cases 
the  deformity  is  of  the  simplest  kind,  the  posi- 
tion of  the  foot  being  an  exaggerated  degree 
of  flexion.  In  ordinary  cases  the  treatment 
required  is  passive  exercise  and  the  use  of  a 
soft  padded  splint  applied  in  front  of  the  leg 
and  foot.  In  severe  cases,  with  much  con- 
traction of  the  anterior  muscles,  the  tendons  of  the  tibialis  anticus, 
extensor  ])roprius  pollicis,  extensor  longus  digitorum,  and  peroneus 
tertius  should  be  divided. 

1  G.  Tiemana  &  Co. 


Fig.  694.1 


Fig.  696.1 


DEFOUMITIES. 


639 


The  apparatus  has  a  steel  spiral  spring,  placed  on  a  pivot  and  plavinj;  be- 
tween brackets  of  the  leg  and  ankle  stein,  to  dt-press  the  front  part  of  the  foot 
bv  exten-^ion;  there  is  not  so  much  danger  of  falling  with  this  apparatus,  when 
descending  stairs.  Or,  instead  of  the  spring,  there  may  be  an  elastic  band  at- 
tached to  the  heel  of  the  shoe  below,  and  to  the  ring  above,  which  consianti}' 
tends  to  elevate  the  heel. 

Non-conirenita!  calcaneus  is  usually  the  rcsitlt  of  infantile  paraly- 
sis, anil,  iis  a  consequence,  tenotomy  is  seldom  required;  palliative 
treatment  alone  must  be  attempted  by  the  application  of  a  j)roper 
shoe. 

.3.  Talipes  varus. ^  in  its  severe  form,  has  the  following  external 
characters  (Fiij.  697),  namely,  the  anterior  portion  of  the  foot  is 
turned  inwards,  forming  a  riizht  an<rle,  the 
sole  looks  directly  backwards  and  the  dor- 
sum forwards  ;  the  inner  border  looks  di- 
rectly upwards,  and  the  outer  directly  <lown- 
wards.  The  first  stage  of  treatment  con- 
sists in  correcting  the  varus  by  turning 
the  foot  outward  into  a  straight  position, 
or  by  bringing  the  sole  squarely 
downwards;  the  second  stage 
consists  in  overcoming  the  ele- 
vation of  the  heel,  equinns,  if 
that  e.xist.  If  the  foot  can  be 
brought  around  nearly  straight 
with  comparative  ease,  the  ef- 
fort shoulil  be  made  by  manipu- 
lation and  bandaging  to  correct 
the  deformity.  This  may  be  effected  by  many  methods  :  (1.)  Ap- 
ply a  strip  of  adhesive  plaster  around  the  anterior  part  of  the  foot, 
commencing  on  the  dorsum  and  passing  around  the  inside,  then 
across  the  sole  to  the  outside,  and  then,  while  the  foot  is  turned 
strongly  outward,  up  the  outside  of  the  leg  to  the  knee; 
over  this  dressing  apply  a  roller  bandage;  repeat  the 
dressing  every  second  day.  (2.)  Apply  a  splint  adapt- 
ed to  tlie  outside  of  the  limb,  with  a  foot-piece  at  an 
angle  with  the  foot,  and,  beginning  at  the  upper  part, 
bandage  the  leg  and  foot  "to  the  splint  (Fig.  G08); 
change  the  dressing  every  second  day,  giving  to  the 
foot  strong  traction  externally.^  (3.)  Give  the  patienti 
chloroform,  and,  after  forcing  the  foot  outwards  fifteen 
minutes,  apply  a  gypsum  bandage  ;  repeat  the  dressing 
weekly .8  In  cases  which  require  tenotomy,  divide  the  lif-W^S- 
tibialis  anticus  and  posticus,  and  if  necessary,  also  the  tendo-achiliis 
1  W.  Adams.  ^  \v.  J.  Little.  8  a.  Ogstoa. 


Fig.  697. 


640 


OPERATIVE  SURGERY. 


and  flexor  longus  digitorum ;  after  the  healing  of  the  wounds,  apply 
the  clubfoot  shoe.  A  shoe  has  been  devised  ^  which  combines  ex- 
tension of  the  foot  with  eversion,  and  excellent  results  have  fol- 
lowed its  use. 

4.  Talipes  valgus  ^  (Fig.  699)  is  rarely  congenital.  Marked 
cases,  without  rigid  muscular  contraction,  may  be 
cured  mechanically  in  a  few  mouths  without  tenot- 
omy; but  severe  cases  demand  a  combination  of 
operative,  mechanical,  and  physiological  means. 
The  tendons  requiring  division  in  the  slighter  cases 
ai'e  the  peronei  and  extensor  longus,  and 
the  tendo-achillis,  if  involved;  in  very 
severe  cases,  the  tibialis  anticus  and  the 
extensor  pollicis  must  also  be  divided. 
The  mechanical  treatment  of  slight  cases 
in  which  the  tendo-achillis  is  not  divided 
is  as  follows:  A  convex  pad  of  vulcan- 
ized India-rubber  is  placed  inside  of  the  boot  in  the  normal  situation 
of  the  arch  of  the  foot  which  it  is  intended  to  support;  it  should  ex- 
tend half  way  across  the  s-ole  of  the  foot,  and  rise  on  the  inner  side 
so  as  to  support  the  navicular  bone;  the  heel  should  be  raised  on 
the  inner  side  about  a  quarter  of  an  inch  so  as  to  twist  the  foot  in- 
wards and  throw  the  weight  on  the  outer  side.  In  more  severe 
cases  it  is  necessary  to  add  a  steel  support,  attached  to  the  outer 
side  of  the  boot  and  carried  up  to  the  calf  of  the  leg,  where  it  is 
connected  with  a  semicircular  steel  plate,  and  a  strap  Avhich  encircles 
the  leg;  a  free  joint  should  correspond  with  the  ankle,  and  a  leather 
strap  attached  to  the  inner  side  of  the  boot  should  pass  across  the 
ankle  joint  and  buckle  outside  the  steel  support.  In  the  most  severe 
cases,  after  tenotomy  is  performed,  a  shoe  must  be  applied  which 
effectually  brings  the  foot  by  degi'ees  into  position. 


Fig.  699. 


IV.    ANCHYLOSIS. 

Anchylosis,^  stiffness  of  a  joint,  is  due  to  pathological  changes  in 
and  around  an  articulation,  as  follows:  (1.)  Cicatricial  adhesions  be- 
tween adjacent  surfaces  of  a  joint.  (2.)  Cicatricial  shrinkages  of 
the  articular  capsule,  of  the  accessory  ligaments,  and  even  of  the 
semilunar  cartilages.  (3.)  Adhesions  of  the  walls  of  the  synovial 
sacs.  (4.)  Bony  deposits  in  the  joint  on  the  articular  surfaces  of  the 
bones  implicated.  (5.)  Loss  of  substance  from  caries,  so  that  the 
epiphyses  stand  obliquely  to  each  other  and  cannot  be  brought  into 
position.  These  changes  are  usually  the  result  of  disease,  but  a 
healthy  joint  will  finally  become  anchylosed  if  kept  immovable  for 

1  N.  M.  Shaffer.  2  ^y.  Adams.  3  T.  Billroth. 


DEFOR}riTIES.  641 

years,  for  the  secretion  of  synovia  is  arrested,  the  synovial  membrane 
becomes  dry  ami  ton;_di,  tlie  cartilages  l>ecoiiie  filamentary,  and  the 
entire  apparatus  finally  elianges  to  a  cicatricial  connective  tissue 
which  may  ossify.  Wiicn  tlie  rigidity  is  dne  to  bony  formations,  it 
is  true  andiylosis,  and  when  caused  by  fibrous  structures  it  is  false 
anchylosis.  Generally,  where  true  anchylosis  exists,  the  sensation 
on  grasping  the  limb  above  and  below  the  joint,  and  on  endeavoring 
to  move  one  part  on  the  other,  is  unmistakeable ;  this  sensation  of 
solidity  is  never  felt  when  the  adhesions  are  fibrous.  As  bony 
anchylosis  is  the  excejition,  and  fibrous  adhesions  infinitely  more 
common,  the  full  effect  of  chluruform  should  alwavs  l)e  obtained  be- 
fore anchylosis  is  pronounced  to  be  liony.  Immobility  alone  is  not 
proof  of  true  anchylosis,  for  it  frequently  exists  where  the  adhesions 
are  fibrous;  and  even  where  the  full  effect  of  chloroform  has  been 
obtained,  so  that  all  muscular  influence  has  been  removed,  immobil- 
ity sometimes  remains  as  great  as  before.  In  the  treatment  of  fibrous 
anchylosis,  when  the  contraction  can  be  entirely  overcome  under  the 
influence  of  an  anaesthetic,  rupture  the  adhesions  ami  place  the  limb 
in  a  condition  of  perfect  rest,  and  apply  ice-l)ags  to  avoid  inflamma- 
tion. If  the  parts  do  not  yield,  remove  such  impediments  to  exten- 
sion as  are  offered  by  contracted  muscles  and  by  tense  fasciae,  by  di- 
viding subcutaneously  all  such  structures  as  are  likely  to  interfere 
with  the  extending  process. 

Cicatrices  and  adhesions  should  be  previously  suljciitaneously  divided,  so  that 
unequal  pressure  may  as  far  as  is  possible  be  removed  durinj^  the  act  of  exten- 
sion, and  especially  from  those  weakest  points  iu  the  neighborhood  of  cicatrices; 
should  the  continuity  of  the  integument  be  cuilaugered  by  the  extension  which 
may  be  necessary  for  the  replacement  of  the  articular  surfaces,  it  is  preferal)le 
to  complete  this  replacement  on  a  second  occasion  rather  than  to  risk  the  small- 
est rent  of  the  skin  ;  those  cases  are  attended  with  the  greatest  success  where 
the  adhesions  are  ruptured  on  the  application  of  moderate  force  and  whicli  yield 
witli  a  single  snap,  wiiere  the  skin  is  in  no  measure  eiulangereil,  where  the  ad- 
hesions are  extra-capsular, and  where  the  integrity  of  the  joint  is  so  far  preserved 
that  there  is  no  tendency  to  dislocation. I  When,  however,  in  consequence  of 
partial  dislocation,  of  extensive  adhesions  within  the  joint,  or  from  other  cause, 
considerable  force  has  to  be  employed,  l)e  careful  as  to  the  direction  and  extent 
of  the  force  used,  especially  when  cicatrices  exist,  that  tlie  integument  may  not, 
by  a  violent  movement  of  the  limb,  be  ruptured;  with  care  this  accident  will 
never  occur;  as  it  is  not  always  possible  to  destroy  all  the  existing  adhesions 
without  endangering  the  continuity  of  tlie  integuments,  it  is  more  [irudent, 
when  great  tension  has  been  induced  and  rupture  of  the  skin  appears  to  be  im- 
minent, to  remit  extension,  and  to  complete  the  operation  on  a  future  occasion. ' 
After  the  subsidence  of  any  iiillauimatioii  <u'  tenderness  which  may  have  been 
induced,  the  remaining  adhesions  will  |)robably  yield  to  gentle  pressure,  or  on 
the  application  of  slight  force. ^  The  ailhesions  having  been  ruptured,  no  fur- 
ther motion  or  examination  of  the  joint  should  be  permitted. ^ 

1  B.  Brodhurst. 
41 


642  OPERATIVE  SURGERY. 

1.  The  phalangeal  joints  ^  are  often  distorted  by  disease,  the  ex- 
tensor muscles  giving  the  direction  to  tlie  displacement  more  fre- 
quently than  elsewhere;  the  extensors  may  prevail  over  one  phalanx 
and  the  flexors  over  another.  In  the  treatment,  section  of  tendons 
is  rarely  required;  the  bent  joint  can  usually  be  straiiihtened  under 
an  anEesthetic  with  the  greatest  ease,  and  the  straight  joints  resume 
their  natural  posture  without  external  aid.  The  straightened  finger 
should  be  put  up  in  the  straight  position,  and  passive  motion  must  be 
resorted  to  and  continued  until  free  motion  is  secured. 

If  anchylosis  is  a  necessity,  the  bent  position  of  a  finger,  so  as  to  touch  the 
thumb,  is  most  useful.^ 

2.  The  wrist-joint  is  rarely  anchylosed  without  more  or  less  im- 
plication of  the  carpal  joints;  when  separately  anchylosed  its  mo- 
tions are  so  largely  supplemented  by  the  carpal  joints  that  its  func- 
tions are  not  impaired  to  such  an  extent  as  to  justify  other  than  the 
most  moderate  efforts  to  overcome  the  stiffness.  The  patient  being 
under  an  anassthetic,  attempt  flexion  and  extension,  carefully  avoid- 
ing too  great  strain  of  the  carpal  joints.  The  after-treatment  re- 
quires rest,  with  applications  of  ice,  for  two  or  three  days,  and  then 
passive  moti(m. 

3.  The  elbow-joint  ^  is  frequently  anchylosed  in  a  more  or  less 
straight  position  which  seriously  diminishes  the  usefulness  of  the 
hand.  In  false  anchylosis,  give  an  anassthetic,  and  secure  rotation 
of  the  forearm  if  possible;  next,  first  move  the  arm  in  the  direction 
opposite  to  that  which  is  especially  to  be  obtained,  that  is,  if  the  joint 
is  too  much  flexed,  flex  the  forearm  still  more;  and  if  too  straight, 
extend  it;  when  the  joint  is  over-flexed,  grasp  it  in  such  a  manner 
as  to  keep  the  thumb  over  the  head  of  the  radius  and  biceps  tendon; 
dui'ing  the  act  of  extension,  make  a  number  of  jerky  actions,  rather 
than  apply  a  steady  force;  if  the  tendon  of  the  biceps  becomes  per- 
fectly tense,  and  the  head  of  the  radius  does  not  follow  the  move- 
ment, the  effort  must  be  discontinued  or  the  tendon  be  divided  to 
avoid  dislocation  of  the  radius.  In  flexing  an  over-straight  arm, 
greater  power  is  secured  by  placing  the  knee  in  the  bend  of  the 
elbow,  care  being  taken  not  to  use  such  pressure  as  will  endanger 
vessels  and  nerves.  If  the  triceps  resist  much,  in  a  person  under 
eighteen,  or  even  more,  if  development  is  retarded,  the  muscle  should 
be  divided.  The  after-treatment  recjuires  rest  and  ice-bags  until  the 
danger  of  inflammation  is  passed,  when  passive  motion  must  be  per- 
severingly  made. 

If  the  anchylosis  is  true,  or  bony,  exsection  may  be  practiced.    The 
steps  of  the  operation  are  the  same  as  for  caries,  except  that  a  tri- 
1  R.  Barwell.  2  x.  Bivant. 


DEFOn^fITIES.  643 

anorular  piece  of  bone  must  be  removed  at  tlie  seat  of  tbe  old  articula- 
tion.    Passive  motion  must  be  early  practiced,  to  prevent  union. 

4.  The  shoulder-joint*  is  rarely  affected  with  true  anchylosis;  it 
is  didieult  of  diagnosis,  owing  to  the  mobility  of  the  scapula.  Pro- 
ceed as  follows  :  tbe  patient  sitting  on  the  floor,  or  on  a  low  stool, 
stand  behind  and  fix  the  shoulder  with  the  thumb  of  one  hand  on 
the  acromion  and  the  fingers  in  the  axilla;  now  lift  the  arm  away 
from  the  side  without  force,  and  in  a  plane  parallel  with  that  of  the 
chest;  if  there  is  any  motion  it  will  be  detected.  To  obtain  motion, 
give  an  anajstbetic,  and  place  the  patient  on  the  opposite  side;  ben<l 
the  elbow  at  riLrht  angles,  and,  using  the  forearm  as  a  lever,  gni^-p 
the  upper  arm  as  liigh  as  possible,  and  rotate  the  humerus,  but  no 
further  outwards  than  is  normal;  when  this  movement  is  free,  jjlace 
the  arm  in  front  of  the  body,  across  the  chest,  till  the  elbow  lies 
in  front  of  the  ensiform  cartilage,  and  rotate  the  humerus  a  little; 
then  place  the  arm  behind  the  trunk  until  the  elbow  lies  just  above 
the  sacro-iliae  synchrondosis,  but  do  not  rotate;  having  loosened  the 
adhesions,  to  a  certain  degree,  again  grasp  the  shoulder  as  at  first, 
lift  the  arm  as  far  as  it  will  go  without  force,  and  commence  circum- 
duction in  as  large  a  circle  as  possible;  the  arm  should  be  brought  to 
at  least  a  right  angle  and  a  half  with  the  body,  and  even  more  eleva- 
tion is  desirable;  considerable  extension  should  lie  made  during  these 
nianceuvers.  Require  rest  in  the  recumbent  position  for  two  or  three 
days,  and  apply  ice-bags;  as  the  tenderness  subsides,  commence 
gentle  passive  motion.  If  the  anchylosis  cannot  be  overcome,  the 
free  movements  of  the  scapula  eventually  give  great  freedom  of  mo- 
tion to  the  arm.'^ 

0.  The  knee-joint  may  be  ancbylosed  at  any  angle,  but  that 
which  is  most  useful  is  the  nearly  straight  position,  which  should  be 
secured,  if  possible,  when  bony  anchylosis  is  impending.  If  the 
angle  is  greater,  the  question  of  an  operation  shoidd  be  decided  as 
follows,  in  fibrous  anchylosis:  (1.)  If  the  limb  be  in  such  posture  as 
to  permit  tolerable  locomotion,  it  is  wrong  to  break  down  an  anchy- 
losis large,  old,  and  inveterate;  enough  to  require  more  thin  a  mod- 
erate exertion  of  force  ;  (2.)  If  the  limb  be  in  a  position  which  ren- 
ders locomotion  hardly  tolerable,  it  is  justifiable  to  use  a  great  amount 
of  force  to  break  down  the  anchylosis  and  restore  the  limb  to  posi- 
tion.' The  operation  of  forcibly  breaking  the  fibrous  structures  about 
the  joint  should  be  performed  as  follows  :  The  patient  being  fully 
anaesthetized,  place  him  in  a  prone  position  with  his  chest  and  face 
elevated;  bring  the  knee  to  the  edge  of  the  table,  and  require  an  as- 
sistant to  hold  the  thigh  firndy  down ;  now  place  the  left  hand  in 
the  popliteal  space,  so  as  to  depress  the  thigh,  and  the  right  on  the 
1  R.  Barwell.  2  T.  Billroth. 


644  OPERATIVE  SURGERY. 

posterioi-  part  of  the  leg  close  above  the  calf  and  on  the  condyles  of 
the  tibia  ;  if  the  anchylosis  is  recent,  and  not  too  firm,  the  leg  will 
gradually  give  way  with  a  soft  crackling  and  tearing;  should  exten- 
sion not  be  so  readily  made,  jjlace  the  hand  lower  on  the  leg,  about 
the  calf  or  close  below  it,  and  use  much  less  force  to  avoid  fracturing 
the  tibia  just  below  the  condyles;  if  these  efforts  fail,  seize  the  leg 
from  the  front  and  attempt  gradual  flexion,  as  adhesions  sometimes 
rupture  more  readily  by  flexion  than  extension;  continue  alternate 
flexion  and  extension  until  the  limb  is  brought  into  proper  position, 
but  avoid  painful  twisting  and  wrenching.^  If  the  patella  is  at- 
ta^'hed,  it  must  first  be  loosened  by  pressure  with  the  thumbs,  or 
aided  by  some  covered  hard  lever. 

One  caiue  of  failure  in  the  treatment  of  fibrous  anchylosis  is  that  the  surgeon 
becomes  alarmed  at  the  audible  fractures  that  occur  and  contents  himself  with 
slight  motion  for  the  present  operation,  intending  to  complete  the  cure  by  sub- 
sequent operations,  and  thus,  by  making  frequent  attempts  to  increase  these 
slight  movements,  he  sets  up  a  new  inflammation  in  the  parts  involved,  pre- 
venting any  further  interference,  and  frequently  resulting  in  a  more  firm  con- 
solidation of  the  joint  than  before;  whereas,  by  breaking  up  the  adhesions 
thoroughly  and  completely  at  the  time  of  operation,  and  then,  by  proper  dress- 
ings of  the  parts  and  the  prevention  of  inflanimation,  he  may  confidently  ex- 
pect that  he  will  have  a  much  more  satisfactory-  result.^ 

The  immediate  dressings  which  most  effectually  prevent  inflamma- 
tion are  applied  as  follows  :2  First  strap  the  toes  with  strips  of  ad- 
hesive plaster  if  it  be  a  small  subject,  or  if  an  adult  with  long  toes, 
pad  the  toes  with  cotton  and  bind  with  bandage,  carrying  the  roller 
over  the  foot  strongly  and  firmly ;  padding  the  malleoli  and  tendo- 
achillis  with  cotton  the  roller  is  carried  snugly  over  them  ;  two  strips 
of  adhesive  plaster  having  been  placed  on  either  side  of  the  leg  for 
extension,  the  roller  is  passed  over  them,  leaving  their  lower  extrem- 
ities exposed  for  the  future  attachment  of  weii^ht  and  pulley,  and  is 
carried  up  as  far  as  the  top  of  the  tibia  ;  pad  the  popliteal  s[)ac(!  and 
firmly  strap  with  strips  of  adhesive  plaster,  each  one  shingling  over 
the  other  until  the  entire  knee  is  covered;  continue  the  roller  over 
the  knee  smoothly  and  very  firmly  to  the  junction  of  the  middle  and 
lower  third  of  the  femur,  when  a  piece  of  sponge  an  inch  or  two  in 
length,  and  about  the  size  of  the  thiunb,  is  placed  over  the  track  of 
the  femoral  artery,  and  the  roller  carried  on  over  this  s[)onge  for  the 
purpose  of  making  partial  compression  of  this  artery,  so  as  to  dimin- 
ish its  calibre  and  thus  prevent  the  full  supply  of  blood  to  the  parts 
below;  great  caution  is  necessary  in  the  application  of  this  pressure 
upon  the  artery  not  to  obstruct  the  circulation  so  as  to  produce  gan- 
grene; then  SL'cure  the  limb  in  an  absolutely  immovable  position 
either  by  a  wooden  splint  well  padded  placed  behind  the  leg,  gutta- 
1  T.  Billroth.  2  L.  A.  Sayre. 


DEFORMITIES. 


G45 


percha,  sole  leather,  plaster  of  Paris,  iron  bars  on  either  side  of  it, 
or  in  any  way  that  best  prevents  the  slightest  possil)le  movement. 
Place  the  patient  in  bed,  the  lower  extremity  of  which  is  raised  ten 
or  twelve  inciics  hi'^hcr  than  the  heail  in  order  that  the  body  may 
act  as  a  counter-extending  force,  and  apply  the  wei.:ht  and  pid- 
ley  over  the  foot  of  the  bed  to  the  strips  of  adhesive  plaster  at 
the  ankle-joint;  place  ice-bags  around  the  knee,  and  use  such  con- 
stitutional treatment  as  may  be  required;  at  the  end  of  six  or  seven 
days  remove  the  dressings,  take  the  sponge  from  over  the  femoral 
arterv,  cut  the  adhesive  stra|)S  from  over  the  knee,  carefully  ex- 
amine the  parts,  and  give  a  very  slight  movement  to  the  joint  for 
the  purpose  of  preventing  solidification;  reapply  the  dressing's  with 
the  sponge  left  off  from  over  the  femoral  artery;  still  continue  the 
extension  and  the  elevated  position  of  the  limb  for  some  days,  until 
all  danger  of  inflammation  is  passed;  at  the  end  of  a  few  days  again 
remove  the  dressings,  and  give  more  free  motion  to  the  part.  It 
may  be  necessary  at  the  time  of  making  this  movement,  and  the 
three  or  four  subsequent  movements,  to  administer  an  ana;-thetic  ; 
these  movements  should  be  made  quite  free  when  an  ana?sthetic  is 
used,  but  not  to  the  point  of  exciting  any  new  inflammation.  After 
some  davs  the  passive  movements  can  be  made  daily,  accompanied 
with  friction,  and  shampooing  should  be  very  liberally  done.  These 
movements  may  be  increased  in  freijucncy  as  the  case  advances,  un- 
til finally  an  instrument  can  be  so  adjusted  to  ihe  limb  that  the  pa- 
tient can  cause  the  movements  many  times  in  the  day  without  the 
attendance  of  his  physician.  So  soon  as  the  parts  can  be  pressed 
together  by  bearing  the  weight  of  the  body  upon  the  foot  without 
tenderness,  the  extension  can  be  omitted,  and  the  movements  daily 
increased. 

The  proper  support  of  the  foot  is  an  important  indication  in  makinp  exten- 
sion. If  the  foot  is  not  well  sustaiiieil,  so 
as  to  be  freely  movable,  the  weijrht  has 
to  be  much  increased,  but  if  the  liml) 
moves  with  no  friction,  the  weight  may 
be  comparatively  liitht.  To  effect  this 
object  a  simple  framework  is  constructed 
wiitch  allows  a  cross  piece  lo  slide  freely 
on  two  horizontal  bars  (Fig.  700). 

If  the  joint  has  long  been  bent 
at  a  right  angle,  not  oidy  do  the 
structures  about  the  joint  contract, 
but  the  condyles  lengthen  so  as  to  render  it  impossible  to  bring  the 
tibia  down  to  its  proper  position,  even  by  dividing  the  re^istin-^  tis- 
sues, as  the  ham  string  tendons  ;  in  such  cases  the  extr»-mities  of  the 
condyles  have   been  cut  away  successfully  with  antiseptic   precau- 


Fifi.  700 


646 


OPERATIVE  SURGERY. 


tions.i  "When  flexion  of  the  leg  and  subhixation  of  the  tibia  is  pro- 
gressing, the  limb  may  be  restored  by  gradual  extension  of  the  joint, 
and  counter  pressure  over  the  upper  extremity  of  the  tibia  (Fig. 
701).2 

The  instrument  consists  of  the  steel  bars  A  and  b,  connected  by  double  joints 
with  the  intermediate  piece  C;  each  bar  has  on  its  end  a  roller  for  the  webbing 

strap  of  the  adhe- 
sive plaster,  and  the 
lower  bar,  b,  has  an 
extension  bar  to 
be  regulated  with  a 
key,  r;  the  leg  rests 
in  the  wide  padded 
bands,  D  and  e, 
which  are  fastened 
to  the  bars  by  a 
Fig.  701.3  ^-^^^^^    ,.;^.^.j    ^J,,^^,^ 

on  each  side,  so  as  to  be  movable  and  fit  exactly  in  every  position;  the  two 
straps,  F  F,  pass  across  the  lower  part  of  the  thigh,  buckling  on  each  side;  a 
third  band,  G,  is  securely  fastened  on  the  upper  end  of  the  bar,  b;  connected 
with  this  band  is  an  extension  rod,  h,  which  passes  through  the  band,  k  ;  ex- 
tension made  with  this  rod  throws  the  head  of  the  tibia  forward  and  downward; 
the  band  k  can  be  put  in  different  positions  hy  the  arrangement  l;  tinaliy,  there 
is  the  extension  rod  ai,  between  the  fixed  bands,  n  and  o. 

If  true  anchylosis  exist  and  the  limb  is  in  such  a  position  as  to  be 
useful,  no  operation  should  be  attempted.  When,  however,  the 
flexion  is  extreme,  the  following  procedures  are  justifiable,  namely, 
amputation  below  the  knee,  exsection  of  the  joint,  or  resection  of 
the  shaft  of  the  femur. 

(1.)  If  the  limb  is  in  a  state  of  atrophy,  amputation  should  be  performed  an 
inch  below  the  tubercle  of  the  tibia  witli  bilateral  flaps;  this  stump  allows  the 
application  of  an  excellent  artificial  limb,  with  direct  bearing  upon  the  knee.* 
(2)  If  the  leg  is  well  developed  a  wedge-shaped  piece  of  bone  should  be  removed 
from  the  knee,  of  such  shape  and  dimensions  as  to  permit  the  foot  to  be  brought 
to  the  ground  at  a  slight  angle,  and  in  this  position  anchylosis  should  be  ob- 
tained.5  The  operation  is  as  follows:  If  the  knee  is  at  right  angles,  preparatory 
to  the  operation,  divide  the  tendons  of  the  biceps,  semi-tendinosus,  semi-mem- 
branosus,  and  gracilis  muscles  several  days  before.  The  tourniquet  having  been 
applied  to  the  upper  part  of  the  thigh,  or  elastic  bandage,  make  an  incision 
from  the  outer  to  the  inner  condyle,  across  the  middle  of  the  patelbi,  and  a 
second  incision  from  the  middle  of  this,  perpendicularly  downwards,  to  the 
tuberosity  of  the  tibia  ;  dissect  the  included  angles  of  integument  down  to  a 
finger's  breadth  below  and  parallel  with  the  margin  of  the  articular  surface  of 
the  tibia:  cut  the  ligamentum  patella?  and  the  fibro-ligamentous  tissues  on  either 
side  on  the  same  level  to  the  extent  of  nearly  two  thirds  of  the  circumference 
of  the  bone.     With  the  amputating  saw  make  a  section  of  the  tibia  at  three 

1  J.  Lister.        2  n.  M.  Shaffer.        3  G.  Tiemann  &  Co.        *  E.  D.  Hudson. 
8  G.  Buck. 


DEFORMITIES. 


647 


fourths  of  an  inch  below  flie  joint  anteriorly,  directed  with  a  slight  obliquity 
upwards,  so  as  to  terminate  at  the  niarj^in  r)f  the  articular  surface  posteriorly, 
c,  I-/ (Fig.  151);  coninu-nce  the  second  section  thnnigh  the  upjier  part  of  the  pa- 
tella, paralli'l  with  the  first,  n,  b,  and  on  a  plane  forming  an  angle  wilh  it,  less 
than  ariglit  angle,  and  cinitinue  to  about  the  same  extent  as  in  the  lirst  section 
with  the  same  saw;  complete  the  remainder  of  the  section  through  the  tibia,  as 
well  as  tlirffugli  the  cnndyles,  wiih  a  metacarpal  saw  and  chi.-els;  remove  the 
included  wedge-shaped  portion  of  bone.  The  after  treatment  is  the  same  as  for 
excision  of  the  knee-joint.  (-3.)  A  section  of  the  femur  may  be  made  ihus:i 
Remove  a  triangular  portion  of  the  shaft,  e,  g,f(V\g.  151);  there  should  not 
be  a  com[)lete  section  of  the  bone  at  its  posterior  |tart,  //. 

6.  The  hip-joint  is  liable  to  be  anchylosed  in  various  j)ositions 
wbich  iiuapiuitate  it.  In  the  diagnosis  of  these  deformities  it  is  im- 
portant fust  to  determine  the  relation  of  the  head  of  tlie  femur  to 
the  aeetabulnm. 

The  following  tests  must  be  made:  (1)  Place  one  end  of  a  tape  measure  on 
the  tip  of  the  anterior  superior  spinous  process,  stretch  the  tape  over  the  diseased 
hip  to  the  most  pri  mincnt  part  of  the  tuberosity  of  the  ischius,  ami  if  the  tro- 
chanter major  has  its  normal  relation  to  the  acetabulum,  the  tape  will  touch  the 

upper  border  of  the  tro- 
chanter major  in  every 
position  of  the  limb. 2 
(2.)  The  ilio-femoral  tri- 
angle 1,  2,  3  (Fig.  702)3 
in  the  normal  condition 
of  parts  is  aright-angled 
triangle,  ami  is  obtained 
thus :  draw  a  line  from 
the  anterior  superior  spi- 
tiG.  702.  nous  process  to   the  top 

of  the  trochanter  major,  1,  2,  draw  a  second  line  from  the  anterior  superior 
spinous  process  directly  downwards  to  the  horizontal  plane  of  the  recumbent 
body,  1,  3;  draw  a  third  line,  3,  2,  the  base  of  the  triangle,  at  right  angles  to 
1,  3;  the  base  line,  3,  2,  is  the  test  line,  being  compared  with  the  same  line  on 
the  opposite  side  of  the  body. 

If  the  hip-joint  is  anchylosed  in  a  fltxed  position  while  the  di.<ease 
is  progressing  in  the  he.ad  of  the  femur  and  aeetabulnm,  the  only  ef- 
fort at  reduction  should  be  by  extension  with  tlie  long  hip  splint,  for 
rude  movements  of  the  bone  are  liable  fo  aggravate  the  caries.  If 
the  di.sease  has  ceased,  and  the  femur  is  fixed  in  an  unnatural  posi- 
tion by  fibrous  anchylosis,  myotimiy  should  be  performed,  and  sub- 
sequently reduction  should  be  attempted  by  force  applied  under  an 
anaesthetic.  If  the  anchylnsis  is  osseous,  and  the  distortion  dis- 
abling, operative  measures  are  justifiable. 

1.  Division  of  the  neck,  subcutaneously,*  is  maile  as  follows:  Rec- 
ognize  the  top  of  the  trochanter,  and   enter  the  kiufe  (Fig.   703) 

1  J.  E.  Barton.  2  £.  NVlaton.  8  T.  Brvant.  ■•  W.  .Vdams. 


648 


OPERATIVE  SURGERY. 


above  it  in  the  direction  of  the  neck ;   open  the  capsule  and  fully  ex- 
pose the  bone;  tlien  pass  the  saw 
(Fig.    704)    along    this    incision, 
which  must   be    maintained    pat-  Fi<;.  703. 

ulous,  until  the  blade  rests  upon  the  neck;  with  a  few  passes  the 

^g  bone   is    divided    at   right 
angles  to  its  axis;  the  saw 
is    then     withdrawn,    the 
Fig.  704.  wound  closed,  and  the  limb 

brought  into  a  proper  position,  and  fixed  on  a  splint.  The  antiseptic 
si)ray  adds  to  the  protection  of  the  wound  from  the  dangers  of  sup- 
puration. 

An  ingenious  instrument  has  been  devised  ^  which  combines  a  sub- 
cutaneous saw,  knife,  and  bone  rasp  (Fig.  705). 

It  consists  of  a  trocar,  fenestrated  caiuila,  1  (Fig.  705),  and  a  staff,  2,  with 
handle  and  blunt  extremity;  a  portion  of  this  staff  at  a  short  distance  from  the 
extremity  is  flattened,  one  edge,  b,  being  made  into  a  knife-blade,  and  the 
other  edge,  c,  being  provided  with  saw-teeth;  this  staff,  2,  is  intended  to  re- 
place tlie  trocar  in  the  canida  after  the  latter  is  introduced;  wlien  in  position, 
3,  either  the  saw,  c,  or  the  knife,  B,  edge  of  the  shaft,  according  to  the  way 
the  latter  is  turned,  corresponds  with  the  opening  in  the  canula;  the  saw  or 

7. 


Fig.  705 


knife  can  then  be  worked  to  and  fro  within  the  canula  by  a  piston-like  move- 
ment, the  canula  being  steadied  by  grasping  the  flange,  d,  at  its  base;  if  it  be 
necessary  to  work  tlie  instrument  as  an  ordinary  blunt-pointed  sheathed  saw  or 
knife,  the  shaft  can  be  fixed  in  the  canula  and  made  into  one  piece  bva  thumb- 
screw in  the  liandle.  All  that  is  necessary  in  using  this  saw  is  to  tlirust  tlie 
trocar  and  cannla  into  the  limb,  the  fenestra  of  the  canula  being  alongside  of 
the  bone  upon  which  the  operation  is  to  be  performed.  The  trocar  is  then  with- 
drawn, the  staff  introduced  in  its  place,  3,  and  worked  as  already  described. 

2.  The  superior  epiphysis  of  the  femur  may  be  resected  above  the 
trochanter  minor  for  true  anchylosis;  the  operation  has  proved  en- 
tirely successful  both  in  regard  to  safety  and  the  usefulness  of  the 
limb.    The  indication  for  resection  at  this  point  is  the  preservation  of 
1  G.  F.  Shrady. 


COMPENSA  Tl  1 1-:   A  PPL lAXCES.  ^49 

tlie  insertion  of  the  psoas  magniis  ami  iliaciis  internus  muscles,  at- 
tached to  the  lower  fragment,  for  the  jxirpose  of  flexion;  the  section 
of  bone  is  (U'si;4ne(l  to  remove  a  semicircular  piece  thus,  -^  with  its 
concavity  downward,  and  by  rounding  ofT  the  tijjper  end  of  the  lower 
section,  to  iiiiitate  tlie  natural  joint.^ 

7.  The  lower  jaw  iniiy  be  aiicliylt)so(l  by  cicatrices  on  one  or  on  Ijoih  sides. 
If  its  movements  are  too  nuicii  restricted,  an  elTort  siiould  be  made  to  open  the 
mouth  by  means  of  an  instrument  wliieh  de- 
scribes the  same  curve  in  opening;  the  bh\des 
as  the  jaw  itself,  and  makes  pressure  \\\wn  tiie 
teeth  directly  upwards  and  downwards.'-  Tlie 
bhides  should  be  covered  with  lead,  or  f^utta 
percha,  to  jirotcct  the  teeth,  and  the  distending 
force  w.ay  be  a  screw  working  vertically  at  the  Yio.  700 

external  ends  of  ihe  blades, 3  or  by  a  wedge  pro- 
pelled by  a  screw  *  (I'ig.  706).  In  apjjlying  these  forces  the  process  of  dilatation 
should  be  very  slow,  the  instrument  being  repeatedly  removed  and  reinserted 
as  far  as  possible,  in  order  to  secure  the  support  of  as  many  teeth  as  are  ex- 
posed. If  the  anchvlosis  is  limited  to  one  side  and  is  unyielding,  section  of  the 
bone  should  be  made  at  the  anterior  margin  of  the  cicatrix,  which  will  enable 
the  patient  to  use  the  free  portion  of  the  jaw.  This  section  may  be  a  sim- 
ple division  of  the  bone ;  5  or  to  more  effectually  prevent  reunion,  a  wedge-shaped 
piece  may  be  removed, 6  three  quarters  of  an  inch  wide  above  and  an  inch  below. 


CHAPTER   LX. 

COMPENSATIVE   APPLIANCES. 

Operative  surgery  may  not  only  fail  to  correct  deformities,  but 
in  its  effort  to  save  life  ni;iy  sacrifice  useful  parts,  and  leave  the  pa- 
tient with  maimed  or  defective  limbs.  The  application  of  apparatus 
to  compensate  the  loss  of  parts  may  be  regarded  as  the  fulfillment  of 
the  final  obligation  of  the  surgeon  to  the  patient.  Too  often  this 
most  important  duty  is  either  imperfectly  performed  or  entirely  neg- 
lected. But  in  the  present  advanced  state  of  mechanic  art  the  sur- 
geon is  culpable  who  does  not  exhaust  its  resources  in  the  effort  to 
restore  both  the  function  and  the  .><ynnnetry  of  lost  parts.  It  is  the 
duty  of  every  surgeon,  therefore,  to  have  that  knowledge  of  compen- 
sative appliances  which  will  enable  him  to  prepare  the  maimed  liinli 
for  the  best  ])Ossible  apparatus,  an<l  to  guide  the  patient  to  a  ju- 
dicious selection. 

Compensative  appliances"  should  be  based  upon  the  philosophical  and  scien- 
tific indications  of  each  case,  anatomically  and  physiologieally  considered.  The 
supplemental  ajiparatus.  intelligently  and  artistically  constructed  and  adapted, 
should  restore  lost  or  crippled  parts  to  their  normal  condition  ant)  usefulness 
as  nearly  as  possible.  It  is  most  important  to  bring  meclianical  surgery  within 
the  circle  of  jirofessional  interest  and  pursuits;   for  an  improved  amputation 

1  L.  A.  Sayre.  2  j.  L.  y.ittle.  »  Rozer.  •»  D.  W.  Goodwillie. 

6  liizzoli.  '  6  F.  Esmarch.         7  £.  D.  Hudson. 


650 


OPERATIVE  SURGERY. 


is  of  no  value  to  the  patient  if  it  is  abandoned  to  the  non-professional,  ignorant, 
and  unappreciative  for  its  ultimate  treatment.  Apparatus  for  palliative,  reme- 
dial, or  compensative  purposes,  as  for  diseased  joints,  lesions  of  nerves,  deform- 
ities, ununited  fractures,  resections  and  amputations,  can  be  safely  and  consist- 
ently intrusted  to  well  educated  and  experienced  physicians  and  surgeons,  who 
are  qualified  to  analyze  the  character  of  the  case,  and  to  perceive  and  define 
what  is  essential  in  apparatus  to  fulfill  specific  indications.  Tliis  requirement 
becomes  imperative  when  apparatus  is  intended  to  supply,  or  reinforce,  ph^'si- 
ological  functions  of  limbs  and  parts  rendered  temporarily  helpless  or  useless 
from  nerve  lesions,  extensive  injury,  and  deformity.  The  numerous  and  niulti- 
plving  cases  of  resections  of  the  superior  and  inferior  extremities,  as  alternatives 
for  amputations,  furnish  occasion  for  the  interposition  of  professional  knowledge 
and  dexterity  to  sustain  and  justify  those  operations  by  the  use  of  legitimate 
apparatus. 

The  following  principle  should  always  govern  in  the  se- 
lection of  prothetic  apparatus,  namely;  in  construction,  the 
mechanism  should  so  conform  to  the  anatomy  of  the  lost  part 
that  all  of  the  normal  functions  will  be  as  exactly  reproduced 
as  possible.^ 


0 


0 


MM 
is 


I.     PSEUD  ARTHROSIS. 

The  failure  of  ossific  union  of  the  ends  of  the 
bones  after  fracture  may  result  in  (1)  union  by 
fibrous  tissue  ;  (2)  extreme  mobility  without 
union ;  (3)  a  rounded  and  pointed  condition  of 
the  fragments  which  are  connected  by  fibrous 
bands ;  (4.)  A  dense  capsule  containing  fluid 
and  the  ends  of  the  bones  round  ami  smooth, 
false  joints. 2  The  causes  of  non-union  are  nu- 
merous, and  should  be  thoroughly  studied  in  each 
case.  It  may  be  due  to  a  want  of  proper  ap[)o- 
sition,  or  syphilis,  or  drunkenness,  or  general 
feebleness.  In  the  treatment,  the  existing  cause 
must,  if  possible,  first  be  i-emoved.  The  subse- 
quent measures  usually  adopted  generally  have 
the  following  order  :  — 

1.  Friction  of  the  fragments  is  produced  by  rubbing 
them  together  briskly,  and  then  the  parts  are  kept  for  a  time  in  a 
state  of  rest;  or  the  patient  is  allowed  to  move  the  limb  slightly. 

2.  The  drill  is  most  useful  in  oblique  fracture. 3  The  common 
drill  (Fig.  707)'*  ma\'  be  employed,  which  works  slowly  owing  to 
its  half-rotation.  A  much  more  perfect  drill  has  been  devised, 5 
which  rapidly  rotates  on  its  axis  by  the  mere  opening  and  clos- 
ing of  the  liand.  Operate  as  follows :  ]\Iake  a  slight  puncture  to 
the  bone  with  a  sharp-pointed  bistoury  ;  introduce  the  drill,  in 
iiG.  /07.''  giich  direction  as  to  enable  it  to  be   carried   through   the  ends  of 


1  E.  D.  Hudson. 
5  G.  F.  Shrady. 


2  G.  W.-Xorris.  3  \v.  Detmold. 

6  G.  Tiemaun  &  Co. 


*  D.  Brainard. 


COM  PENS  A  TIVE  A  PPUANCES. 


G,31 


the  fragment.*,  to  wound  llieir  surface?,  and  to  transfix  whatever  tissue  may  be 
placed  between  thf-ni,  withilraw  it  from  tlie  bone,  but  not  from  tlie  skin,  cliange 
its  direction  and  perforate  again;  repeat  tliis  operation  three  or  four  times;  place 
the  liml)  in  a  condition  of  perfect  rest,  with  a  well  applied  gypsum  bandage,  and 
maintain  tliis  dressing  for  three  weeits. 

3.  Subcutaneous  section  of  tiie  ligamentous  structures  may  be  safely  made 
■with  a  narrow  blad(-d  knife;  an  effort  should  be  made  to  separate  these  tissues 
from  the  ends  of  the  l)iinL'.     The  gypsum  dressing  must  be  applied. 

4.  Resection  and  suture  of  the  extremities  of  the  bones  is  followed  by  im- 
mediate results,  but  the  ojx-ration  has  all  the  features  of  a  compound  fracture, 
and  should  not  be  practiced  in  the  thigh.  Make  an  incision  down  upon  the  bone, 
dissect  out  the  two  fragments,  excise  them,  perforate  close  to  the  end,  pass  a 
tirm  silver  wire  and  twist  the  ends  together;  i  the  antiseptic  dressings  must  be 
used,  as  they  render  this  operation  free  frou)  dangerous  suppuration. 2 

In  ca.«es  which  resist  all  these  measures,  or  which  are  not  adapted 
for  such  treatment,  the  last  resource  is  the  application  of  suitable  ap 
paratus  which  will  enable  the  patient  to  use  the  limb.  It  often  hap- 
pens that  under  such  treatment  the  patient  regains  vigorous  health 
and  the  ])ones  become  firndy  consolidated.  It  is  a  (jneslion  yet  to  be 
determined  whether  these  appliances  ought  not  to  be  far  more  gen- 
erally employed  in  jdace  of  the  preceding  operations. 

In  the  application  of  such  apparatus,  remember,  (1)  that  the  pressure  at  the 
seat  of  fracture  is  as  great  as  can  be  borne  without  inflaming  the  skin;  (2)  that 
in  the  lower  extremities,  the  weight  of  the  body  is  sustained  by  the  upper  part 
of  the  hollow  splint,  just  as  a  stump  is  sustained  in  an  artificial  limb  after  am- 
putation; the  upper  strap  should,  therefore,  be  firmly  drawn  when  the  patient 
is  about  to  walk;  but  slackened  when  in  bed  or  sitting  up  in  a  chair  ;  (.3)  when 
worn  for  several  months  the  inside  lining  and  stuffing  should  l>e  renewed,  so  as 
to  give  accurate  support ;  (4)  When,  from  union  occurring,  it  is  pro|X)sed  to  lay 
aside  the  splint,  let  it  be  taken  off  at  night  for  ten  days,  or  whilst  sitting  up  in  a 
chair,  before  any  attempt  is  made  to  walk  without  it.3 

1.  The  ulna  and  radius  occasionally  fail  to  repair  after  fracture, 
when   an  jijiparatiis  like  the 
following    may    be    usefully 
employed   (Fig.   708).^ 

It  consists  of,  A,  piece  accu- 
rately embracing  the  arm;  B, 
joint  for  tie.xion  and  extension  of 
forearm  at  elbow;  b,  pivot-joint 
permitting  rotation  of  head  of 
radius  in  senii-pronation  and  su- 
pination; C,  ensheathing  piece  for 

forearm;  n,  a  thick  pad  to  press  Fi<;.  708. 

on  styloid  jjrocesses  of  ulna  and  radius  at  their  carpal  surfaces 
serve  the  parallelism  of  these  bones. 

1  T.  Billroth.  2  J.  Lister.  8  H.  H.  Smith 


so  as  to  pre- 


652 


OPERATIVE   SURGERY. 


The  humerus  is  more  often  the  locality  of  non-union  than  any 
other  lione.  An  apparatus  for  its  relief 
should  fit  closely  to  the  rotundity  of  the 
shoulder,  and  should  also  embrace  the 
forearm  (Fig.  709),  being  accurately 
jointed  at  the  elbow. 

3.  The  tibia  rarely  remains  ununited 
after  the    application   of    the   drill   and 
moderate  exercise    with   an    immovable 
apparatus.     If   non-union  continue,   ap- 
ply   a   more   durable    appa- 
ratus. 

This  should  consist  of  the  fol- 
lowing; parts  (Fig.  710):  i  A,  sup- 
port at  middle  of  thigh;  b,  knee- 
joint  in  side-irons;  c,  main  sup- 
port of  the  body  by  accurate  adjustment  below  the  tubercle  of  the  tibia  ;  i>,  ankle- 
joint  and  boot.     Or,  the  splint  -  may  extend  from  beneath  the  head  of  the  tibia 
to  the  malleolus,   and  continue  from 
an  ankle  joint  to  a  plantar  plate,  ar- 
ranged one  inch  from  beneath  the  foot, 
and  allow  the  foot  to  be  attached  to  it 
to    overcome   the   shortening;    strong       t||[ 
l«;ather  bands  and  a  graduated  splint 
contine   the   limb    and    fragments  of       ^;||^J! 
bones    in    position,   while   a    padded 
leather  band  beneath  and  steel  straps, 
with  joints  at  the  knee,  extend  from 
the  leg-bonnet  up  the  inner  and  outer 
aspects   of  ilie   thigh,  to  attach  to  a 
thigh  ca'^e ;  this  affords  efficient  counter 
extension  and  support  (I'ig.  711). 

4.  The   patella  rarely   unites 
by  bone,  and  there  is  irreat  lia- 
bility that  by  sudden    flexion   of 
•  the  leg  the  fibrous  adhesions  will 
be   ruptured.       It    is    important 
that  patients  suffering  from  im- 
perfect union  should  wear  a  sup- 
port to  the  knee  which  not  only 
sustains    the    parts    firmly,    but 
which   will    prevent   flexion   be- 
yond   a   given  degree. 
If  the  patella  is  united  by  a  very  weak  ligament,  it  is  so  impaired 
in  function  that  the  power  of  extending  the  leg  upon   the  thigh  is 
1  H.  H.  Smith.  2  E.  D.  Hudson. 


Fig.  710. 


Fig.  711. 


COMPESSATIVE  AI'PfJANCES. 


Go3 


greatly  dirnini.-hfd,  and  sonietiiiu'S  lu-arly  lost.  This  function  may 
be  preserved,  wlien  slii^litly  impaired,  l)y  a  simple  apparatus,  con- 
sisting of  a  leather  knee-cap,  strength- 
ened posteriorly,  and  maintained  in 
position  by  buckles.  If  the  loss  of 
power  is  very  disabling,  the  apparatus 
should  be  more  firm,  and  have  a  hinge- 
joint  posteriorly,  c  (Fig.  713),'  strong 
bands,  A  B,  a  ring  acting  over  the  an- 
terior part  of  the  joint  i>,  with  lateral  bands  f  f.  When  the  func- 
tion is  lost  by  si'paration  of  the  fragments,  the  njiparatus  must  com- 
pletely compensate  the  loss  of  power  of  the  (luadrici-ps  extensor 
(Fig.  719)  by  a  spring  at  the  joint. 
A  very  useful  apparatus  (Fig.  712)  consists  of  a  cap  of  buckskin  or  satin 

jean,  adjustable 
to  llie  knee  by 
buckles  or  laces, 
and      provided 
with  a   pair   of 
coaptutiiin  pads,  j. 
to     retain     the 
newly   united    patella 
in    place;    these   pads 
are    arranged    to    ap- 
proximate by  drawing 
on  laces  of  the  cap  ;  it 
affords  the  patient  ex- 
ercise   of    the    knee- 
joint,  the  best  guard 
against  the  danger  of 
anchvlosis,  at  the  same 


time    prcventnig   any 
undue    strain    on    the 


Fig.  71.3. 


newly  united  upjier  fragment  of  the  pattlla. 

5.  The  femur,  next  to  the  humerus, 
most  trecjuently  fails  of  union.  The  dis- 
abling effect  of  this  result  is  of  the  most 
serious  character.  Of  the  various  opera- 
tive methods  of  attempting  to  secure  union 
all  should  be  discarded  in  favor  of  the 
splint,  which  enables  the  patient  to  re- 
sume active  exercise. ^ 

The  apparatus  should  consist  (Fig.  714)  of  a 
shoe,  to  which  are  attached  two  steel  braces  with  ankle  and  knee  joints,  and  a 
bipband  attached  by  a  joint ;  the  leg  and  thigh  are  firmly  supported  by  leather 
splints  with  stout  buckles. 

1  F.  Bacou.  -  E.  D.  Hudson. 


654 


OPERATIVE  SURGERY. 


11.    PARALYSIS. 

The  various  forms  of  paralysis  affecting  tlie  extremities  may  be 
relieved  by  sipparatus. 

1.  The    fingers  occasionally   suffer  paralysis  of 
les,  giving-  only  flexion  of  the  fin- 
ulition  may  be  greatly  relieved  by 
IS  (Fig.  715),  which  constantly  ex- 
tends the  fingers  and  wrist. ^ 

2.  The  wrist  may  fall  into  the 
position  of  flexion,  wrist-drop, 
tVom  paralysis  of  the  extensors  of 
tlie  carpus.  This  uuil-position  is 
readily  rectified  by  a  simple  in- 
strument, which  makes  elastic 
jiressnre  on  the  thenar  and  hypo- 
thenar  eminences  (Fig.  71G). 

3.  The  forearm  and  arm  af- 
fected by  paralysis  require  the 
appliances  recommended  for  un- 
united fracture. 

4.  The  ankle  is  often  weak 
from  paralysis  of  the  muscles  at- 


FiG.  716. 

tached  to  the  bones  of  the  foot.  The  joint  is 
easily  strengthened  by  apparatus  with  lateral  steel 
braces  fastened  to  the  shoe  (Fig.  717). 

Three  rivets  are  attached  to  the  sole  of  a  common  laced 
shoe,  a  lateral  stem  is  jointed  at  the  ankle, 
«,  passing  as  high  as  the  centre  of  the  calf, 
and  here  fixed  to  a  hand,  b.  The  ankle  is 
supported  and  kept  in  its  corrected  posture 
by  a  triangular  V-shaped  leather  strap,  c, 
'17.  acting  against    and    buttoned   to   the   steel 

stem  on  the  opposite  side.     The  best  direc- 
„  the  side  on  which  the  instrument  should  be  applied,  is,  that 
if  the  outer  ankle  has  a  tendency'  to  eversion,  the  apparatus  should  invariably 

1  E.  D.  Hudson. 


tion  for  selecting 


COMPENSATIVE  APPLIANCES. 


655 


Fig.  718. 


be  placed  to  the  inner  side,  and  rice  vers)t.  In  obstiinite  cases  it  is  made  with 
double  stems,  in  order  to  f^ive  f^reater  security,  and  to  keep  the  sole  in  a  strictly 
horizontal  plane:  the  ankle  may  be  further  protected  by  a 
small,  round,  soft  pad,  to  prevent  dialing  against  the  steel. 

5.  The  leg  may  suffer  frcjin  paralysis  of  some  of  its 
muscles  so  as  to  be  too  feeble  to  sustain  the  weight  of 
the  body.  The  best  apparatus  has,  with  a  shoe,  le" 
and  thigh  belt,  lateral  steel  bi-aces,  with  ankle  and 
knee  joints,  and  elastic  bands  supporting  the  ankle 
and  knee  (Fig.  718). 

G.   The  thigh  may  suffer  from  pai-alysis  of  various 
muscles,    but  the  most   important 
is  the  (juadriceps  femoris;  inaijiiit\ 
to  extend  the  leg  upon  the  thigli 
results  from   its  paralysis  or  rup- 
ture, and  the  patient  is  no  longer 
able   to  walk.      This  condition   is 
S  relieved    by    an    apparatus    (Fig. 
719).     The  instrument  consists  of 
steel  supports,   and  strong  elastics 
attached    to    cords,    workinof 
upon  eccentric  leverages;  the 
kni'e   is  entirely  free  from  all 
|)ressMre,  and  after  the  leg  is 
bent  by  the  flexors,  extension 
of    the    leg    u])on    the    thigh 
promptly  occurs. 

In  cases  of  infantile  paraly- 
sis, with  atrophj'  and  shorten- 
ing of  the  limb,  it  is  very  diffi- 
cult to  su])plement  the  loss  by 
any  ordinary  lueans.  The  limb 
not  only  has  to  be  strength- 
ened, but  also  to  be  length- 
ened, in  order  to  restore  its  function.  This  may 
be  effected  by  the  following  apparatus  (Fig.  720), 
namely,  two  upright  steel  bars,  k,  attached  to  the 
shoes,  j)ass  up  either  side  of  tlie  leg  nearlv  to 
the  knee;  they  are  then  curved  l):H'kward  to  the 
middle  of  the  popliteal  space,  where  thev  unite 
in  a  stop  joint.  A,  whicli  allows  partial  bendin"' 
Fig.  720.  "^  ^^^^    knee;    from   this    point    two   lateral  steel 

bars,  K,  diverge  and  pass  upon  either  side  of  the 
thigh,  the  external  as  high  as  the  trochanter  major,  G,  and  the  inter- 


656 


OPERATIVE  SURGERY. 


nal,  nearly  to  the  groin;  to  the  upper  ends  of  these  bars  two  bands 
are  attached,  the  posterior  being  thickly  padded  and  resting  under 

the  tuber  ischii,  and 

the  anterior,   D,   of 

lighter    material ;    a 

knee-cap,  m,  main- 
tains the  leg  in  position  by 
means  of  lateral  straps;  two 
light  bamls  jiass  around  the 
leg,  c,  and  the  thigh,  b;  the 
shoe  has  an  inside  elevated 
sole  to  which  the  foot  is 
attached,  and  which  per- 
mits support  on  the  foot  in 
the  act  of  walking.  The 
effect  of  the  apparatus  is  to 
rentier  the  defective  limb 
of  the  same  length  as  the 
well  limb;  the  spine  being 
thereby  straightened,  and 
the  steps  made  equal;  the 
body  is  carried  on  the  pos- 
terior band.  This  appa- 
ratus is  adapted  to  cases 
of  hip-joint  disease  in  the 
stage  of  recovery,  for  slight 
traction  may  constantly  be 
made. 

7.  The  thigh  and  leg  affected  by  paralysis  of  the  muscles  re- 
quire the  same  apparatus  as  the  preceding,  but  it  should  be  extended 
so  as  to  embrace  the  hip  by  a  belt  (Fig.  721)  to  which  the  elastic 
straps  are  attached. 

8.  Both  lower  limbs  may  be  paralyzed,  and  yet  the  patient  may 
be  enabled  to  resume  the  upright  position,  and  walk  about.  The 
apparatus  is  simply  the  latter  instrument  made  double  (Fig.  722). 


Fig.  722. 


III.  DANGLE  LIMBS. 
The  flail-like  movement  of  the  upper  extremities,  after  resection 
of  bones  and  exsection  of  joints,  frequently  renders  them  entirely 
useless  without  apparatus,  but  with  this,  suitably  constructed  and  ad- 
justed, these  limbs  become  very  serviceable.  The  apparatus  should 
consist  of  arm  and  forearm  pieces,  with  a  hinge-joint  at  the  elbow 
(Fig.  723);  the  whole  apparatus  being  maintained  in  connection 
with  the  trunk  by  shoulder-straps. 


CO.yfPEXSA TIVE  APPIJAXrES. 


Co 


IV.    ARTIFICIAL  LIMHS. 
The  application  of  artilicial  limbs  to  siipplcnicnt  the  losses  oci*a- 
sioned  by  amputation  must  be  regarded   as  the  highest  expression 
of  mechanical  art.     The  perfection  of 
the    mechanism    of    these    appliances, 
when  produced  by  slcilled  labor,  is  not 
excelled   in  any   branch  of  human  in- 
vention.    Hands   and   arms,   feet   and 
k'fs,  may  now  be  obtained  which  are 
scarcely  less  useful,  and  are  often  even 
more   ornamental,    than    the    original 
limbs.     And  these  a[)pliances  are  now 
within  the  reach  of  the  most  huu)ble 
person.     The   surgeon    can   no  longer 
ignore  these  facts  and  discriminate  be- 
tween the  rich  and  poor  man's  stumps; 
nor  can  the   selection   of  these  appli- 
ances longer  be  left  to  the  patient  himself,  who  is 
liable  to  be  imposed  upon  by  mere  manufacturers, 
having  no  adequate  knowledge  of  the  proper  func- 
tions of  the  apparatus  which  they  are  required  to 
supply.     It  not  unfrequently  happens  that  the  sur- 
geon does  not  so  fully  understand  the  mechanism 
of  these  appliances  as  to  be  qualified  to  advise  in 
their  selection.     Such  ignorance  implies  also  a  want 
of  good  judgment  in  the  formation  of  the  stump  to 
which  the  appliance  is  to  be  adjusted,  and  has  re- 
ceived judicial  condemnation.     The  important  prin- 
ciple to  be  constantly  borne  in  mind,  in  adapting 
stumps  to  artificial  limbs,  is  the  necessity  of  ade- 
quate leverage,  and  a  well-composed  and  compact 
covering.^ 

1.  The  fingers,  individually  or  as  a  group,  may  be  supplied  with 
apparatus  which  admits  of  seizing  and  grasjjing.     The  fingers  should 

be  so  placed  and  moved  as 

to  enable  the  normal  thumb 

to  oppose'  each  one  at  all  of 

its  articulations,  and  when 

the   fingers   are  closed   the 

thumb  should  be  in  position 
to  close  over  the  first  and  second.  If  the  thumb  alone  is  lost,  the 
substitute  should  be  a<lapted  to  o[>j)ose  the  fingers  (Fig.  724).  If 
the  thumb  and  forefinger  are  supplied,  they  must  be  in  a  state  of 

1  E.  D.  Hudson. 
42 


Fig.  724. 


Fig. 


658 


OPERATIVE  SURGERY. 


opposition  for  the  purpose  of  grasping,  but  the  latter  must  be  sus- 
ceptible of  easy  extension  (Fig.  7'25). 

2.  The  hand  and  forearm  are  best  supplemented  when  the  stump 
is  made  above  the  wrist-joint  and  through  the  lower  portion  of  the 

shaft  of  the  ulna  and  radius;^  the  bulbous  extremity 
of  the  radius,  when  the  stump  is  at  the  wrist  joint,  is 
not  adapted  to  the  form  of  socket  of  the  artificial  limb. 

The  position  of  the  fore 
and  second  fingers  and 
thumb,  should  be  as  far 
as  possible  that  of  oppo- 
sition when  closed.  Pro- 
Fig.  726.  nation  and  supination  are 

secured  in  the  forearm,  and  the  flexion  and  extension  of  the  carpus 
are  affected  by  cords  acting  through 
springs  (Fig.  726).  The  cords  may  be 
acted  upon  by  the  movements  of  the 
opposite  shoulder    (Fig. 
727). 

The  spiral  ."pring,  i  (Fig. 
727),  draws  the  lingers,  f, 
constantly  towards  the  ^' 
thumb,  d,  and  retains  anv|| 
article  placed  within  the 
hand  and  between  the  thumb 
and  fingers;  the  hand  may 
be  opened  by  a  motion  of 
the  opposite  shoulder  draw  '^'  '-'^■ 

ing  on  the  shoulder  strap,  m,  and  cord,  h,  or  by  extending  the  artificial  hand 
and  arm ;  the  fingers  are  constructed  on  the  metallic  bar,  g. 

3.  The  arm  and  fore-arm,  with  the  hand,  are  supplied,  in  ampu- 
tations in  the  arm,  by  apparatus  which  derives  its  motion  from  the 
stump;  the  backward  motion  extends,  and  the  forward  motion  flexes 
the  joints  of  the  arm  and  forearm. 

In  these  cases  the  upper  arm  consists  of  a  socket  to  receive  the  stump  of  the 
Hull),  and  is  secured  by  straps  to  the  person  with  a  certain  degree  of  rigidity; 
till'  anterior  and  posterior  tendons  or  rods  have  a  firm  attachment  at  or  near  the 
shoulder,  pass  along  or  through  the  upper  section,  and  are  attached  to  such 
l>nints  on  the  forearm  that,  as  one  or  the  other  is  tightened,  the  forearm  is  flexed 
or  extended;  in  some  cases  the  oscillation  of  the  elliow-articulation  is  obtained 
by  cords  which  have  direct  or  intermediate  attachment  to  the  forearm,  in  others 
the  cords  or  bars  move  a  toothed  wheel  which  engnges  a  pinion  on  the  elbow 
axis  and  gives  motion  to  the  forearm;  the  backward  motion  of  the  stump  tends 
to  strain  the  anterior  tendon,  which  is  so  connected  to  the  forearm  behind  the 
elbow-joint  as  to  extend  the  forearm;  the  forward  motion  of  the  stump  strains 
the  posterior  tendon  which  connects  to  the  forearm  in  front  of  the  articulation, 


rOMPEMSA  TI  \  E   A I  'PL  I A  Xt'ES. 


659 


and  thus  flexes  it  as  the  stump  is  moved  forward.  These  motions  follow  the 
iialmal  ones,  as,  for  instance,  in  the  act  of  raisint;  the  iiand  to  the  mouth  it  is 
Usual  to  oscillate  the  arm  forward  on  tiie  shoulder  as  a  pivot,  and  liacicwardlv 
as  the  hand  descends;  in  the  natural  arm  the  pivotal  position  of  the  forearm  is 
varied  so  as  to  cause  the  arm  to  swin^  in  an  arc  which  will  briny  the  hand  to 
the  required  place,  as  the  mouth;  in  the  ariilicial  arm,  the  motion  on  the  shoul- 
der is  the  generator  of  the  motion  on  the  elbow,  and  a  certain  amount  of  prac- 


tice and  adjustment  is  required  to  proportion  the  parts  so  that  the  consentaneous 
action  of  the  parts  which  i)roduce  the  compound  motion  may,  without  apparent 
constraint  or  indecision,  land  the  hand  at  the  object.  When  the  trunk  of  a  per- 
f«n  affords  points  of  attachment  for  the  flexor  and  extensor  straps,  the  motions 
of  the  shoulder  itself,  relatively  to  the  thorax,  and  involving  the  clavicle  and 
scapula,  may  be  made  to  assist  in  executing  the  motions  required.  The  primary 
motion  of  the  stump  having  been  communicated  to  the  forearm  by  the  means 
described  (or  other  special  devices  which  are  various  and  very  ingenious),  the 
motions  of  the  hand  are  derived  from  that  of  the  forearm  by  tneans  of  tendons, 
slides,  or  other  attachments  (1  ig.  728). 

4.  The  toes  iiiny  be  siippk-iiiented  by  iirtificial  iiieaiis,  but,  in 
giMieral,  a  boot  pi'oviiled  with  a  huav)-  sole  answers  every  purpose  in 
piogicssion.     Tlie  same  is  true  of  amputation  of  llie  metaearpus. 

5.  The  foot  cannot  be  adequately  substituted  when  the  amputa- 
tion is  below  the  ankle-joint. 

The  tarso  metatarsal  and  niedio-tarsal  i  amputations  will  not  hereafter  be  per- 
formed where  there  e.xist  intelligent  and  humane  regard  for 
improved  surgery, and  the  greatest  benetit  of  the  sufferer; 
the  operations  are  in  no  respect  conservative  nor  creditable 
to  the  surgeon  who  makes  them. 2 


The  ankle-joint  stump  affords  space,  firmness,  and 
levera;j;e  for  the  artificial  foot,  ami  should  be  pre- 
ferred whenever  any  consideralile  portion  of  the 
foot  must  suffer  amputation,  and  when- 
ever any  of  the  soft  tissues  of  the  heel, 
or  beneath  the  malleolus,  or  of  the  dor- 
sum of  the  foot  are  suHicient  to  consti- 
tute either  a  sinsle  or  double  flap,  even 
if  necessary  to  form  the  cicatrix  over  the  conical  part  of  the  base 
of  the  stiimp.^  The  appliance  should  have  only  flexion  and  exten- 
sion at  the  ankle-joint  (Fig.  '29),  and  flexion  of  the  toes. 

1  Chopart.  -  1--  D-  Hudson. 


660 


OPERATIVE  SURGERY. 


6.  The  leg-stump  may  be  formed  at  any  part,  but  the  apparatus 
is  tlie  same  in  each  case.  The  foot  should  be  of  the  same  mechanism 
as  in  the  ankle-joint  stump,  namely,  a  socketed  axial 
bolt  passing  transversely  through  it,  giving  only 
flexion  and  extension  (Fig.  730).  The  construction 
of  the  leg-piece  is  designed  to  give  lateral  support' 
by  a  well  shaped  and  fitting  socket;  a  thigh  piece 
with  joints  in  the  steel  side  pieces  is  necessary  to 
sustain  the  limb,  and  elastic  straps  are  sometimes 
added  which  are  attached  to  a  yoke  strap  over  the 
shou'der. 

7.  The  knee-joint  amputation  leaves  a  broad, 
well-covered  stump,  which  readily  takes  direct  sup- 
port, and  hence,  with  a  well-adjusted  appliance,  is 
extremely  serviceable.     The  foot  and  leg  pieces  are 
the   same   as  those  already  given.     The  knee-joint 
may  be  perfect  in  the  motions  of  flexion  and  exten- 
sion,  and    the 
padded  socket 
should   be   ex- 
actly   adapted 
Fig.  7-30.  to  the  form  of 

the  stump.  The  thigh  should  lace  up  in 
front,  and  straps  may  be  added  to  sus- 
tain the  whole  upon  the  shoulder.  The 
same  apparatus  is  necessary  when  the 
amputati  ;n  is  at  the  point  of  election, 
for  by  flexion  of  the  short  stump  the  bear- 
ing is  taken  on  the  condyles  of  the  femur 
in  the  same  manner  as  in  knee-joint  am- 
putation. 

8.  The  thigh  amputation  requires  a 
socket  extending  to  the  hip,  with  bands 
attached  which  may  be  applied  over  the 
shoulder  to  su])port  the  apparatus.  The 
construction  of  other  parts  is  the  same 
as  in  amputations  at  the  knee.  In  cases 
of  double  amputation  these  appliances 
may  be  adapted  to  both  legs,  so  that 
the  individual  will  have  good  motion^ 
(Fig.  731). 

9.  The  hip-joint  disarticulation,  though  the  severest  form  of  mu- 


FiG.  731. 


1  E.  D.  Hudson. 


COMPENSATIVE  APPLIANCES.  661 

tilation,  admits  of  lln-  aj)|)lication  of  a  nio.'^t  ii-oful  liinh,  tlirougli  the 
niedium  of  u  gutta  jierclia  bonnet  coiiforined  to  tliu  tiitin-  iko-luiu- 
bar  parts. 

cui:vATUi:i:s  at  tiii:  kxke. 

The  knee-joints  occasionally  beeonie  ^o  weak  ihniugli  relaxation 
of  the  ligaments  as  to  retjuire  eompensative  applianees  to  enal»le  the 
patient  to  walk  with  any  freedom.  The  relaxations  are  due  to  slight 
anomalies  of  formation,  or  too  feeble  development  of  those  parts,  and 
the  results  are  manifested  espeeially  at  the  time  when  the  growth  is 
most  vigorous,  and  the  ends  of  the  bones  assume  the  final  form.^ 
Rickets  is  the  most  frequent  cause  of  bending  of  the  iiones  of  the  lee, 
and  relaxation  of  the  ligaments  of  the  knee-joint.  The  curvatures 
are  of  two  kinds. 

1.  Genu  varum,  bow-Icf^s-,  depends  upon  relaxation  of  the  external  lateral 
ligament  of  tlie  knee  and  slirinkajie  of  the  inteniul  lateral  ligament,  except 
when  it  is  due  tn  liendiiig  inwards  of  the  femur. i 

2.  Genu  valRuni,  knock-knee,  results  generally  from  relaxation  of  the  in- 
ternal lateral  ligament,  and  shrinkage  of  the  external  ligament,  with  secondary 
contractions  of  the  l>iceps  femoris.i  In  some  cases,  especially  those  induced  by 
rickets,  there  is  not  only  lengihening  of  the  internal  and  shrinkage  of  the  ex- 
ternal lateral  ligaments,  liut  there  is  overgrowth  of  the  internal  condyle  to  such 
extent  as  to  prevent  straightening  the  limb. 

In  the  early  stages  the  weight  of  the  body  should  be  taken  from 
the  knee,  either  by  contlnenniit  with  a  side  splint  to  which  the  knee  is 
firmly  bandaged,  or  by  allowing  exercise  with  the  common  hip  splint 
(Fig.  25)  properly  applied.  In  later  stages  apparatus  is  useful  wdiich 
straightens  the  limb,  and  su])ports  it  by  means  of  a  steel  brace  ap- 
plied upon  the  concave  side,  with  bands  around  the  leg  and  thigh, 
and  a  cap  for  the  knee.  If  both  knees  are  affecteil,  an  appiiratus 
must  be  applied  to  both  lind)s  from  the  hips  to  the  feet,  not  unlike 
that  required  in  paralysis  of  both  limbs  (Fig.  722).  If  the  external 
ligament  is  very  tense  and  unyielding,  and  the  internal  condyle  is 
not  lengthened,  it  may  be  found  inq)OSsible  to  straighten  the  limb 
without  first  rupturing  or  dividing  these  tissues. 

The  effort  to  forcibly  straighten  the  limb  is  often  so  great  as  to  fracture  the 
femur  in  addition  to  rupturing  parts,-  and  though  the  results  liave  been  favor- 
able, previous  tenotomy  is  the  preferable  inethoil.' 

If  the  deformity  is  due  to  curvature  of  the  femur  or  tiljia,  these 
bones  should  be  straightened  by  refracture  with  the  chisi-l  and  mal- 
let, and  united  in  the  straight  position.  In  those  eases  in  which  the 
internal  condyle  has  become  lengthened,  which  will  be  apparent  on 
inspection  and  manipulation,  the  deformity  can  be  overcome  onh'  by 

1  T.  Billroth.  2  Delore.  «  H.  A.  Reeves. 


662 


OPERATIVE  SURGERY. 


operative  procedures.  Section  of  the  internal  condyle  must  be  made 
(Fig.  732)  with  a  view  to  its 
replacement  and  reunion  on  a 
higher  level  (Fig.  733).  This 
method  is  to  be  preferred  to  that 
of  opening  the  joint  and  ri-niov- 
ing  the  redundant  articular  sur- 
face which  has  been  safely  prac- 
ticed antiseptically.i  The  same 
objection  may  be  made  to  section 
of  the  condyle  with  the  saw, 
though  the  operation  has  been 
very  successful,  antiseptic  pre- 
cautions being  used. 

This  operation  2  on  the  adult  ie  as 
follows  :  Flex  the  knee  as  far  as  pos- 
sible,  and   turn  the  thigh   outwards; 
Fig.  732.  introduce  a  lonjr  and  strong  tenotome 

knife,  three-and-a-half  inches  above 
the  tip  of  the  internal  condyle  on  the  inner  side  of  the  thigh,  and  so  far  bade  as 
to  be  opposite  the  ridge  of  bone  running  between  the  linea  aspera  and  the  con- 
dyle; carry  the  blade  forwards,  downwards,  and  outwards  over  the  front  of  the 
femur,  with  its  cutting  edge  directed  to  the  bone;  when  its  point  is  felt  under 
the  skin,  in  the  groove  between  the  condyles  where  the  patella  would  normally 
have  been  lying  in  the  flexed  position,  divide  the  soft  parts  and  periosteum  by 
withdrawing  the  knife ;  through  the  cut  thus  made  introduce  a  narrow  saw,3 
and  divide  the  condyle  nearly  to  the  popliteal  space;  now  forciblystraighten  the 
knee,  and  the  remaining  attachments  of  the  condyle  will  be  readily  fractured. 

The  following  operation  is  free  from  the  objections  which  apply  to 
those  methods  involving  a  more  or  less  free  opening  of  the  knee- 
joint:*  Introduce  a  scalpel  covered  with  carbolized  oil  just  above 
the  most  prominent  part  of  the  internal  tuberosity,  and  divide  the 
soft  parts  and  periosteum;  insert  by  the  side  of  the  knife  a  chisel, 
also  dipped  in  carbolized  oil,  and  with  a  few  strokes  of  the  mallet 
penetrate  the  condyle  to  its  greatest  depth,  but  only  as  far  as  the 
cartilage  covering  it ;  the  direction  of  the  chisel  should  be  first  to- 
wards the  intercondylar  groove,  then  partially  withdrawn,  and  its 
direction  altered  forwards  and  backwards,  until  the  condyle  is 
loosened,  but  not  separated.  Place  a  pad  of  lint  saturated  with  car- 
bolized oil  over  the  incision,  and  apply  a  long  straight  splint  to  the 
outside  of  the  leg,  with  a  bracket  at  the  knee;  at  the  end  of  two 
weeks  apply  an  immovable  apparatus,  as  gypsiun,  and  retain  it  for 
three  or  four  weeks  in  children,  and  six  to  eight  in  adults,  when 
passive  motion  must  be  begun  and  persevered  in  until  the  func- 
tions of  the  joint  are  completely  restored. 
1  T.  Annandale;  J.  Lister.      2  a.  Ogstou.      ^  ^y.  Adams.        *  H.  A.  Keeves. 


II^DEX 


Abdomex,  anatomy  of,  431. 

hernia;  of,  436. 
Abdominal  aneurism,  256. 
aoria,  ligation  of,  257. 
lierniif  4^6. 
Abnormal  anus,  401,  419. 
Abscess  of  abdominal  walls,  433. 
of  alveolar  process,  358. 

antrum,  469. 

brain,  285. 

breast,  585. 

ca;cum,  398. 

kidney,  498. 

liver,  426. 

nasal  fossoe,  464. 

pharynx,  376. 

salivary  glands,  363. 

spine,  1G6. 

tongue,  370. 

tonsil,  366. 

vermiform  appendix,  397. 
Acne  rosacea,  320. 
Acromio-clavicular  dislocation,  149. 
Actual  cautery,  25. 
Acupuncturators,  329. 
Acupuncture,  application  of,  329. 
Acupressure,  23. 

in  aneurism,  225. 
Adhesive  plaster  dressing,  46. 
.(Estiversion,  25. 

Affections,  nervous,  after  wounds,  70. 
Age  in  prognosis,  7. 
in  operations,  7. 
Air  in  the  veins,  38. 
Alimentation,  rectal,  408. 
Alveolar  process,  abscess  of,  358. 
dentigenous  cysts  of,  359. 


Alveolar  process,  vascular  growths  of, 

359. 
Ammonia  in  collapse,  37. 

in  narcosis,  35. 
Amputation,  atomizer  for,  593. 
at  elbow  joint.  608,  609. 
hip  joint,  629-632. 
knee  joint,  626,  627. 
shoulder  joint,  611-013. 
considerations  regarding,  590. 
instruments  f<ir,  592. 
methods  of,  594. 

by  bilateral  flaps,  596. 
double  flaps,  .590. 
periosteal  flaps,  597. 
rectangular  flap,  596. 
single  flap,  595. 
circular,  594,  595. 
division  of  bone,  597. 
of  arm,  610,  611. 
fingers,  'jOl,  602. 
forearm,  607. 
leg,  624-620. 
metacarpal  bones,  603. 
penis,  588. 

phalanges,  599,  600,  614. 
thigh,  628. 
thumb,  602. 
tibia.  62-3. 
toes,  614. 
place  of.  591. 
preparations  for,  591. 
supra-malleolar,  624. 
through  metatarsal  bones,  616. 
time  of.  .590. 
wound,  care  of,  598. 
.Vmygdalotomy,  367. 


664 


INDEX. 


Amj'l  nitrite  in  narcosis,  35. 
Ansesthesia,  26. 
general,  27. 
local,  30. 
Anaesthetics,  27. 
chloroform,  29. 
nitrous  oxide,  27. 
sulphuric  ether,  27. 
rapid  respiration,  30. 
Anchylosis,  causes  of,  640. 
of  elbow  joint,  642. 
hip-joint,  647. 
knee-joint,  643. 
phalangeal  joints,  642. 
shoulder  joint,  643. 
wrist  joint,  642. 
Aneurism,  221. 

abdominal,  256. 
arterio-venous,  219. 
by  anastomosis,  220. 
symptoms,  221. 
treatnient,  221. 
cirsoid,  220. 
gluteal,  256. 
iieo-femoral,  256. 
popliteal,  257. 
varicose,  219. 
needles,  233-235. 

use  of,  234. 
treatment,  222,  233. 
by  acupressure,  225. 
compression,  224. 
constriction,  225 
elastic  bandage,  22.3. 
electrolysis,  223. 
flexion,  223. 
foreign  bodies,  223. 
injection,  222. 
ligation,  223,  233. 
manipulation,  222. 
Aneurismal  varix,  219. 
Angioma,  plexifurm,  231. 
Angiomala,  cavernous,  230. 
Ankle  joint,  excision  of,  179. 
braces  for,  161. 
caries  of,  160. 
disarticulation  at,  621,  622. 
dislocations  of,  153. 
compound,  153. 


Ankle  joint,  weakness  of,  654. 
Antiseptic  dressing,  44. 
agents,  42. 
method,  42,  58. 
Anthrax,  315.  , 

seat  of,  316. 
Antrum,  anatomy  of,  469. 
abscess  of,  469. 
dropsj'  of,  469. 
Anus,  abnormal,  401,  419. 
absence  of,  418,  421. 
anatomy,  416. 
and  rectum,  421. 

artificial  in  intestinal  wounds,  401. 
contraction,  417. 
exploration  of,  417. 
fistula  in,  423. 
tissue  of  the,  421. 
vaginal  fistula  in,  419. 
vesical  fa?cal  listula  in,  420. 
Aorta,  abdominal,  ligation  of,  257. 

aneurism  of  arch,  237. 
Apparatus,  compensative,  649. 
for  dangle  limbs,  656. 
femur,  653. 
humerus,  652. 

non-united  fractures,  651-653. 
paralysis,  654-656. 
patella,  652. 
tibia,  652. 

ulna  and  radius,  651. 
plastic,  53. 
Applications,  endermic,  328. 
Apnoea,  35. 

Arm,  amputation  of,  610,  611. 
artificial,  658. 
paralysis  of,  654. 
Arterial  compression,  19. 
by  fingers,  20. 
key,  20. 
ligature,  21. 
tourniquet,  20. 
hasmorrhage,  215. 
thrombosis,  220. 
Arteries,  anatomy  of,  23-3. 
acupressure,  23,  225. 
compression  of,  224. 
contusion  of,  214. 
diseases  of,  220. 


INDEX. 


665 


Arteries,  general  operations  on,  233. 

ligation  of,  223,  233. 

rupture  of,  '214. 

wounds  of,  215,  216. 
Arterio-vcnous  aiieuri:!ni,  21!). 
Arteriotoniy,  233. 
Artilicial  limbs,  656-059. 

respiration,  35. 
nietliocU  of,  36. 
Ascites,  tapping  in,  435. 
Aspiration  of  intestines,  393. 
Aspirator,  501. 
Astragalus,  resection  of,  133. 

dislocation  of,  153. 
Atheroma,  221. 
Atomizer,  473. 

antiseptic,  593 
Atrophy  of  nails,  322. 
Axillary  artery,  aneurism,  246. 

ligation  of,  249. 
methods,  250,  251. 

relations,  249,  251. 

Bandages,  circular,  .50. 

double-headed,  52. 

elastic,  18. 

application,  18. 
in  aneurism,  223  . 

figure  of  eight,  52. 

gypsum,  54. 

recurrent,  53. 

roller,  50. 

silica,  55. 

spica,  52. 

spiral,  51. 

starch,  54. 

T,  53. 

dangers  of,  50. 

materials  for,  50. 
Battery,  galvano-cautery,  369. 
Bilateral  lithotomy,  521. 
Bisector,  522. 
Bistoury,  liiryngeal.  480. 
Bladder,  anatomy  of,  502. 

aspiration  of,  511. 

calculi  of  the,  512,  513. 
in  women,  526. 

exploration  of,  503. 

extroversion  of,  505. 


Bladder,  foreign  bodies  in,  511. 

inflammation  of,  .509,  510. 

ru|)lure  of,  507. 

wounds  of,  508. 
Bleeding,  37. 
Blood-letting,  209,  272,  273. 

local,  272,  273. 
cupping,  273. 
leeching,  272,  273. 
scaritication,  273. 

rules,  209,  272. 
Boils,  cause  and  treatment,  315. 
Bones,  caries,  107. 

diseases  of,  101. 

general  operatiims  on,  111. 

inflammation  of,  106. 

injuries  of,  8. 

meiacarpal,  amputations  of,  003. 
disarticulations  of,  603-606. 

metatarsal,  amputation  at.  010. 
disarticulation  of,  610-018. 

necrosis,  109. 

rickets,  101, 

tumors,  102. 
Bougies,  bulbous,  529,  537. 

filiform,  537. 
Brachial   artery,    anatomy,   251-253. 

ligation  of,  251. 
methods,  251-253. 
precautions,  252. 

ple.xus,  297. 

resection,  297,  298. 
Brain,  abscess  of,  285. 

bruising  of,  270. 

commotion  of,  275. 

compression  of,  270. 

concussion  of,  275. 

contusion  of,  270. 

hernia  of,  277,  285. 

inflammation  of,  283. 

wounds  of,  277. 
Breast,  abscess  of.  585. 

extirpation  of,  588. 

intlammation  of,  588. 

scirrhus  of,  587. 

tmnors  of,  587. 
Bristle  probang,  377. 
Bronchi,  anatomy  of,  490. 

foreign  bodies  in,  490. 


666 


INDEX. 


Bronchocele,  varieties  of,  489. 
Burns,  degrees  of,  312. 

cicatricial  contractions  in,  313. 
Bursse,  deep,  198,  199. 
inflammation  of,  198. 
deltoid,  198. 

ligamentum  patellfe,  199. 
quadriceps  extensor,  198. 
superficial,  199. 
wounds  of,  198. 

Caecal  abscess,  398. 
Cfficum,  abscess  of,  398. 
anatomy  of,  396. 
intussusception  of,  399. 
perforation  of  appendix,  397. 
wounds  of,  396. 
Cesarean  section,  570. 
Calculi  of  salivary  glands,  363. 
Calculus,  renal,  499. 
vesical,  512. 
seat  of,  513. 

operations  for  removal  of,  513. 
of  urethra,  534. 
extraction  of,  535. 
Callosity,  313. 

treatment,  314. 

Cancer  of  the  nose,  469. 

of  the  tonsil,  .367. 

colon,  405. 

penis,  557. 

treatment,  558. 
rectum,  415. 
testicle,  551. 
tongue,  .372. 

operations  for  removal,  372- 
.374. 
uterus,  571. 
Carbolic  acid  dressing,  42. 
Caries  of  bone,  107. 
central,  108. 
external,  109. 
fungating,  156. 
internal,  109. 
of  joints,  156. 

ankle  joint,  160. 
carpal  joints,  161. 
hip  joint,  158. 
knee  joint,  160. 


Caries  of  tarsal  joints,  161. 

of  vertebrse,  162. 

simple,  156. 

superficial,  107. 
Carcinomata,  105. 
Care,  degree  of,  3. 
Carotid,  common,  aneurism  of,  238. 

direction  of  arteries,  239. 

external,  ligation  of,  242. 
wounds  of.  216. 

internal,  ligation  of,  242. 
wounds  of,  216. 

ligation  of,  2.39-241. 

relations,  2-39,  240. 

wounds  of,  216. 
Carpal  joints,  caries  of,  161. 
Case  of  instruments,  15. 
Castration,  551. 
Catch  forceps,  22. 
Catgut  ligature,  22. 
Catheter,  iNIercier's,  554. 

sigmoid,  576. 

Squires',  554. 

velvet-eyed,  529. 
Catheters,  503,  529. 

introduction  of,  504. 

selection  of,  503. 
Catheterism,  prostatic,  553,  554. 

in  the  female,  544. 

in  the  male,  504. 
Cauterization,  25. 

actual  cauter3',  25. 

thermo-cautery,  26. 
Cellulitis,  causes,  316. 

treatment,  317. 
Chain  saw,  114. 
Chilblains,  311. 

treatment,  312. 
Chisel,  116. 
Chloroform,  29. 

administration,  29. 
Cholecystotomy,  429. 
Chondromata,  103. 
Cicatrices,  growths  on,  339. 
Cicatricial  contractions,  337. 

causes,  337. 

operations  for,  337-339. 

selecti(m  of  methods,  338. 
Cicatrix,  adherent,  78. 


INDEX. 


007 


Cicitrix,  contracted,  78. 

defective,  77. 
prevention,  78. 

exuberant,  78. 
forms  of,  78. 

painful,  79. 

variations,  77. 
Cicatrization,  normal,  73. 
Circular  edf^e  saw,  115. 
Circulatory  system,  diseases  of,  220. 

aneurism,  221. 

bv  anastomosis,  220. 
cirsoid,  220. 

atheroma,  221. 

injuries  of,  210. 

thrombosis,  arterial,  220. 
venous,  22.5. 
Cirsoid  aneurism,  220. 
Clamp,  Bodenhamer's,  558. 

nasal,  402. 

Thomas,  564. 

varicocele,  547. 
Clavicle,  fracture  of,  82. 
treatment,  83. 
union  in,  84. 

relations  of,  130. 

resection  of,  128. 
methods,  129,  1.30. 

shot  fracture  of,  97. 
Claw  force])s,  22. 
Claw  nails,  324. 
Cleansing  of  wounds,  40. 
Cleft  palate,  351. 

operations  for,  352. 

varieties  of,  351. 
Club-foot,  036-640. 

appliances  for,  037-039. 

rules  for  treatment,  030,  637. 

shoes,  6.37,  6-38. 
Coccj'x,  resection  of,  137. 
Collapse,  symptoms  of,  38. 
Collodion  in  wounds,  46. 
Colon,  anatomy  of,  400,  403. 

cancer  of,  405. 

section  of,  403. 

stricture  of,  401. 

wounds  of.  400. 
Colotomy,  after-treatment,  405. 

operation  of,  403. 


Compression,  after  fracture,  034. 
arterial,  19. 
by  fingers,  20. 
key,  20. 
ligature,  21. 
tourniquet,  20. 
elastic,  18. 
in  aneurism,  224. 
'      methods,  224,  225. 
in  incised  wounds,  304. 
of  brain,  276. 
of  nerves,  282. 
Compound  fractures,  95. 
ana'sthetics  in,  95. 
antiseptics  in,  95. 
delinilion,  95. 
indications,  95. 
plastic  dressing,  95,  96. 
reduction,  95. 
Conclusion  of  operation,  34. 
Concussion  of  the  lungs,  494. 
of  brain,  275. 
symptoms,  275. 
treatment,  275. 
of  the  spine,  278. 
ha-morrhage  in,  279. 
in  railway  injin-ies,  279. 
symptoms,  primary,  278. 

secondary,  279. 
treatment,  279. 
Conformity  to  established  rules,  3. 
Consent  to  operation,  11. 
Constitutional  diseases  in  prognosis,  7. 
Constitution,  nervous,  291. 
Constriction,  24. 
advantages,  24. 
a|)plication,  25. 
in  aneurism,  225. 
Constrictor,  24. 

Contraction  of  soft  palate,  356. 
of  anus.  417. 

treatment,  417. 
cicatricial,  199.  200,  .3.37. 
Contusions,  appearances,  303. 
degrees  of,  .302. 
of  arteries,  214. 

treatment.  214. 
of  brain,  27<!. 
treatment,  276. 


668 


INDEX. 


Contusions  of  nerves,  seat  of,  282. 
symptoms,  282. 
treatment,  282. 

of  scrotum,  545. 

of  veins,  217. 
treatment,  218. 
varieties,  217. 
Convalescence,  nurse,  15,  16. 

room  for,  16. 

ward  for,  16. 
Cord,  spermatic,  liaeniatocele  of,  548. 

hydrocele  of,  548. 

varicose  veins  of,  548. 
Corn,  treatment  of,  314. 
Cotton  wool  dressing,  44. 
Cranium,  trephining  of,  291. 

indications  for,  291,  292. 

inflammation  within,  283. 
Croupous  granulation^,  75. 
Cuboid  bone,  resection  of,  132. 
Cuneiform  bone,  resection  of,  132. 
Cupping,  instruments  for,  273,  274. 
Curved  saws,  115. 
Cutaneous  horn.  314. 
Cystic  tumors  of  ovary,  561. 
Cystitis,  acute,  509. 

chronic,  510. 
irrigation  in,  510. 
Cysts,  dentigerous,  360. 

ovarian,  561. 

Day  for  operations,  13. 
Decision  as  to  operation,  10. 
Delirium  tremens  after  operations,  71. 
Delirium  nervosum  after  operations,  71. 
Dentigerous  cysts.  359.  360. 
Diagnosis,  elements  of  correct,  5. 

history  of  patient,  6. 

progress  of  disease,  6. 
Digital  nerves,  resection  of,  299. 
Dilator,  Gouley's,  518. 
Diligence,  what  constitutes,  3. 
Director,  31. 
Disarticulation  :  at  ankle-joint,  621. 

medio-tarsal,  619. 

metacarpal,  603-606. 

of  metatarsal  bones,  616-618. 
tarsus,  620. 
toes,  614,  615. 


Disarticulation  :  radio-carpal,  606. 

tarso-metatarsal,  618. 
Diseased  granulations,  74. 
Dislocations,  148. 

acromico-clavicular,  149. 
compound,  148. 
definition,  148. 
general  treatment,  148. 
of  ankle  joint,  153. 
elbow  joint,  150. 
hip  joint,  151. 
knee  joint,  153. 
patella.  153. 
phalanges,  153. 
shoulder  joint,  149. 
tarsal  bones,  153. 
vertebrie,  149. 
wrist  joint,  151. 
signs  of,  148. 
sterno-clavicular,  149. 
temporo-maxillary,  148. 
Dissection,  31. 

in  ligation  of  arteries,  236. 
Divulsion  in  strictures,  540,  541. 
Divulsors,  urethral,  540,  541. 
Dog  forceps,  21. 
Dorsalis  pedis  artery,  ligation  of,  268. 

penis  artery,  ligation  of,  260. 
Douches,  nasal,  460. 
Drainage  of  wounds,  41. 

tubes,  167. 
Drains,  application  of,  41. 

materials  for,  41. 
Dressing,  adhesive  plaster,  46. 
antiseptic,  41. 

rules  governing,  40. 
principles  of,  39. 
bandages  for.  50. 
cotton  wool,  44. 
collodion,  46. 
of  wounds,  39. 
by  adhesive  plaster.  46. 
antiseptic  method,  41,  58. 
carbolic  acid,  42. 
cotton  wool,  44. 
collodion,  46. 
interrupted  suture,  46. 
twisted  suture,  47. 
quilled  suture,  47. 


rXDEX. 


6G9 


Dressing  of  wounds,  preparation.  40. 
principles,  39. 
hot  water,  49.  59. 

ordinarj",  4.5,  .58. 

plastic  apparatus,  53. 
Drill,  in  fmcture,  650. 
Duo<lenuni,  anatomy  of,  388. 

foreign  bodies  iu,  388. 

wounds  of,  389. 

gunshot  of.  391. 

Ecchyniosis,  217. 
Elastic  bandage,  18. 

application  of,  18. 
compression,   18. 
rings,  19. 
application  of,  19- 
Elbow,  di>location  of,  150. 
forms,  150. 
reduction,  150,  151. 
Elbow-joint,  amputations  at,  608,  609. 
anchylosis  of,  642. 
excision  of,  173. 

after  treatment,  176. 
metbotis,  175. 
mortality  after,  174. 
motions  of,  173. 
results  of,  174. 
subperiosteal,  175. 
Electricity  in  collapse,  -38. 
Electric  probe,  308. 
Electrolysis,  in  aneurisms.  223. 
Elements  of  correct  diagnosis,  5. 
Elephantiasis  arabum,  319. 

of  scrotum,  546. 
Elevators,  145. 
Emergencies,  34. 

air  in  the  veins,  88- 
bleeding,  37. 
narcosis   34. 
shock.  37. 
Emphysema,  495. 
Encephalf»cele.  287. 
Eiidemiic  applications,  328. 
Endoscope,  503,  528. 
Enterotome,  392. 
Enterorrhaphy,  390. 
Epididymitis,  549. 
Epigastric  artery,  ligatioD  of,  261. 


Epispadias,  532. 
Epistaxis,  462. 
Epithelioma  of  labia,  577. 

of  skin,  320. 
Epulis,  3.58. 

Eretliitic  granulations,  74. 
Erysipelas,  complicating  wound.*,  64. 
Erysi|>elatous  inflammation,  314. 
Erythema,  63. 

Established  rules,  confonnitv  to,  3. 
Ether,  27. 

administration  of,  27,  23. 
apparatus  to  administer.  28. 
Examination,  5. 
physical,  6. 
Excision  of  testicle  in  varicocele,  230. 
of  joints.  168. 
indications,  168. 
methods,  168. 
of  ankle  joint,  179. 
elbow  joint,  173. 
hip  joint,  187. 
knee  joint,  182. 
metacarpal  joints,  169,  179. 
nietacar|>o-iarsal  joints,  179. 
phalangeal  joints,  169,  179. 
shoulder  joint,  176. 
tarsal  joints,  179. 
wrist  joint,  169. 
time  of,  168. 
Exostoses,  103. 
Exploration  of  anus,  417. 
of  rectum,  405. 

mefhotls  of.  406. 
of  uterus,  566. 
of  vagina,  571. 
Extension,  after  fracture,  6-34. 
Ejciirpation  of  ovaries,  560. 
of  the  tongue,  372-374. 
of  rectum,  415. 

after-treatment,  416. 
of  prostate  and  bladder,  416. 
larynx.  480. 
methods  of.  481.  482. 
Extraction  of  teeth,  360. 
bicuspids,  361. 
cuspids.  361. 

dentes  sapientiie,  .361,  362. 
incisors,  361. 


670 


INDEX. 


Extraction  of  teeth,  indicationG  for,  360. 

instruments  for,  360,  361. 

molars,  361,  362. 
Extroversion  of  bladder,  505. 

treatment,  506. 

by  operation,  506. 
Exuberant  granulations,  77. 

Facial  artery,  ligation  of,  243. 
nerve,  anatomy,  297. 
section,  297. 
Fascia*,  contractions  of,  200,  201. 
Fasciatomy,  202. 

Femur,  non-united  fracture  of,  653. 
fracture  of,  88. 
direction,  88. 
in  children,  91. 
point  of,  88. 
treatment  of,  88-90. 
resection  of,  136. 

methods  of,  136,  137. 
shot-fracture  of,  99. 
Femoral  artery,  anatomy,  262. 
ligation  of,  262. 

"methods,  262,  263. 
wounds  of,  217. 
Fever,  inflammatory,  66. 
hectic,  69. 
pyremic,  69. 
septic,  69. 
traumatic,  66. 
Fevers  complicating  wounds,  65. 
classification,  66. 
development,  66. 
Fibromata,  105. 
Fibrous  tumors,  soft,  320. 

uterine,  568. 
Fibula,  resection  of,  134. 
Fingers,  amputations  of,  GOl,  602. 
artilicial,  657. 
distortion  of,  634,  642. 
flexion  of  joints  of,  634. 
paralysis  of,  654. 
supernumerar}',  633. 
webbed,  6-33. 
Fissure  of  anus,  421. 
dilatation  in,  423. 
examination  of,  422. 
symptoms,  421. 


Fissure  of  anus,  treatment,  422,  423. 
Fissures  of  skull,  277. 
of  base,  277. 
symptoms  of,  277, 
treatment  of,  277. 
with  scalp  wound,  277. 
Fistula  in  ano,  423. 

examination  for,  424. 
operative  methods,  424,  425. 
blind,  422. 
vaginal,  419. 
vesical,  fiwal,  420,  421. 
vesico-vaginal,  574. 
Fistulas  of  salivar3-  glands,  363. 
Flexion  in  aneurism,  223. 
Foot,  artificial,  659. 
Forceps,  in  amputation,  598. 
bone,  114,  116. 
bull-dog,  21. 
catch,  22. 
claw,  22. 

curved  serrated,  366. 
needle,  575. 
oesophageal,  378,  379. 
pharyngeal,  curved,  376. 
serrated,  574. 
suture   47. 
tenaculum,  21,  866. 
tongue,  357. 
tonsil,  366. 
with  slide,  21. 
wire  twisting,  351. 
Forearm,  amputation  of,  607. 
artificial,  657. 
paralysis  of,  654. 
Foreign  bodies  in  aneurism,  223. 
in  bladder,  511. 

removal  of,  512. 
in  bronchi,  490. 
duodenum,  389. 
larynx,  475. 
nose,  464. 
oesophagus,  378. 
pharynx,  376. 
rectum,  414. 
stomach,  387. 
thoracic  cavity,  492. 
trachea,  484. 
urethra,  534. 


INDEX. 


671 


Fractures,  81. 

compound,  95. 
aiia'stlietics  in,  95. 
antiseptics  in,  95. 
definition  of,  95. 
indications  in,  95. 
plastic  dressing  in,  95,  96. 
reduction  of,  95. 
diaj^nosis  of,  81. 
examination,  80. 
gypsum  splints,  81,  92,  9-3,  94. 
of  clavicle,  82. 
femur,  88. 
fibula,  93. 
humerus,  84. 
inferior  maxilla,  81. 
laryngeal  cartilages,  474. 
olecranon  process,  87. 
patella,  91. 
radius,  85. 
and  ulna,  63. 
ribs  and  cartilages,  82. 
skidl,  277,  278. 
depressed,  278. 
of  base,  277. 
the  spine,  280. 
lesion  of  cord  in,  280. 
prognosis  in,  280,  281. 
seat  of,  28t),  281. 
tibia,  92. 
and  fibula,  9-3. 
plastic  apparatus,    81,    8-3,   88,   90, 
92-94. 
bandages,  81,  53,  90. 
shot,  96. 
simple,  80. 
ununited,  650. 

apj)liances  for,  651-653. 
Fibula,  fracture  of,  93. 
Free  torsion,  23. 
Frost-bite,  311. 
Fulcrum,  575. 
Furuncles,  315. 

Gall  stones,  429. 

cholecystotomy  in,  429. 
Galvano-cautery,  369. 
Ganglia,  197,  198. 
Gangrene  during  repair,  CI. 


Gangrene,  hospital,  02. 

phageda-na,  02. 

traumatic,  61. 
Gastrotomy,  -388. 
Gastrostomy,  482. 

after-treatment,  -384. 

indicati(jns  for,  382. 

oiierative  methods,  382,  384,  385. 
Gastrorhaphy,  386. 
General  ana-stliesia,  27. 
Genu  valgum  and  varum,  601. 
Gland,  thyroid,  anatomy  of,  488. 

e.xeision  of,  489. 

hypertrophy  of,  488. 

prostate,  hypertrophy  of,  552. 
Glands,  sebaceous,  321. 

salivary,  362. 
abscesses  of,  363. 
anatomy  of,  362. 
calculi  of,  363. 
fistuhc  of,  363. 
tumors  of,  364. 
wounds  of,  362. 
Glanders,  311. 
Glossitis,  370. 
Gluteal  aneurism,  256. 

artery,  ligation  of,  259. 
Goitre,  488. 
Gouges,  lie. 
Grafiing,  method  of,  76. 
Granulations,  diseased,  74. 

croupous,  75. 

erethitic,  74. 

exuberant,  77. 

indolent,  75. 
Growths,  laryngeal,  478,  480. 

of  alveolar  process,  359. 

vascular,  359. 

warty,  359. 

horny  of  nails,  324. 
Gunshot  wounds,  305. 

after-treatment,  310. 

by  cannon  balls,  -306. 
irregular  missiles,  .307. 
musket  balls,  -306,  307. 
small  projectiles,  306. 

examination  of,  307. 

instruments  for  diagnosis,  308. 

nature  of,  306. 


672 


INDEX. 


Gunshot  wounds,  removal  of  projectile, 
308 

of  lungs,  494,  495. 
Gypsum  jacket,  1G3,  165. 

splint,  54,  81,  88,  92-94. 

splint  for  hip,  192. 

when  applied,  81. 

bandage,  83,  90. 

ankle  brace,  161. 

knee  brace,  160. 

tarsal  dressing,  162. 

Habits  in  prognosis,  8. 
Hsematocele,  of  spermatic  cord,  548. 

of  testicles,  549. 
Haemorrhage,  17. 

during  repair,  secondary,  60. 

intermediarj',  60. 

parenchymatous,  61. 

in  incised  wounds,  303. 

umbilical,  434. 

from  the  lungs,  495. 

acupressure  in,  23. 

aertiversion  in,  25. 

arterial  compression  in,  19. 

cauterization  in,  25. 

constriction  in,  24. 

ligation  in,  21. 

torsion  in,  22. 

from  nose,  462. 
Hifimorrhoids,  227,  414. 

clamp  for,  558. 
HEcmo-thorax,  496. 
Hair  follicles,  retained  secretions,  321. 

overgrowth  of,  320. 
Hand,  artificial,  656. 
Hare-lip,  double,  342. 

single,  341. 

operations  for.  342. 

rules  for  operating,  341. 

varieties  of,  340. 
Heart,  wounds  of,  213. 

extraction  of  foreign  bodies,  214. 

normal  position  of,  233. 

operations  on,  2-32,  233. 
Hectic  fever,  69. 
Hemp  ligature,  22. 
Hernia,  abdominal,  436. 
contents  of,  4-37. 


Hernia,  cerebri,  277,  285. 
femoral,  450. 

strangulated,  451. 
inguinal,  442. 
anatomy,  442. 
direct,  449. 

oblique,  strangulated,  446. 
operation  for,  446. 
radical  cure  of,  445. 
trusses  for,  443,  444. 
varieties  of,  443. 
irreducible,  438. 

operation  for,  441. 
reducible,  diagnosis  of,  437. 
operation  for,  438. 
truss  for,  438. 
sac  of,  436. 
strangulated,  438. 
umbilical,  452. 
strangulated,  454. 
treatment,  453,  454. 
varieties  of,  436. 
pulmonary,  495. 
Hip,  splints  for,  159. 
dislocations  of,  151. 
reduction,  152. 
varieties,  151. 
Hip-joint,  anatomy,  629. 
amputation  at  the,  629. 
hy  circular  method,  683. 
double  flaps,  6-30. 
single  flaps,  630. 
oval,  632. 
anchylosis  of,  647. 
excision  of,  187. 
after-treatment,  191,  192. 
indications,  188. 
methods  of,  189,  190. 
mortality  after,  187. 
period  of  operation,  188. 
results,  187. 
caries  of.  158. 
splints  for,  159. 
History  of  patient,  6. 
Hook,  double  for  uvula,  357. 
Horn,  cutaneous,  314. 
Horny  growths  of  nails,  324. 
Hospital  gangrene,  61. 
Hot-water  treatment  of  wounds,  49. 


INDEX. 


673 


Hour  for  operations,  1.3. 
Humerus,  fracture  of,  84. 

non-united  fracture  of,  052. 
resection  of,  124. 
after-treatment,  124. 
metiiods  of,  124-I2(!. 
mortality  after,  124. 
shot  fracture  of,  'J7. 
Hydroceplialus,  285. 
acquired,  28G. 
compression  in,  286. 
conijenital,  285. 
tafipiiifj  in,  285. 
Hydrocele,  547,  548. 
Hydrophobia,  311. 
Hydronephrosis,  501. 

aspiration  in,  502. 
Hymen,  imperforate,  577. 
Hj-pertrophy  of  tlie  tongue,  370. 
of  tonsils,  3G«. 
lips,  343,  344. 
nails,  323. 
spleen,  430. 
alveolar  process,  359. 
Hypodermic  injections,  331. 
needles,  331,  -332. 
rules  for,  332. 
sN'finges  for,  331. 
solutions  for,  332. 
Hypospadias,  529. 

operative  methods,  5.30-532. 
Hj'sterotome,  5G7. 

Ileum,  intussuscejition  of,  392. 

obstruction  of,  395. 

strangulation  of,  394. 

wounds  of,  389,  390. 
Iliac  arteries,  ligation  of,  257,  258,260. 

common,  257. 
anatomy  of,  257. 

external,  2(!0. 

internal,  258. 
Ilio-femoral  aneurism,  256. 
Imperforation  of  rectum,  408. 
Imperforate  anus,  417. 
treatment,  418. 

nose,  461. 

uretiira,  529. 
Incised  wounds,  .303. 

43 


Incised  wounds,  hjrmorrhage  in,  .303. 
ligation  in,  .304. 
torsion  in,  .304. 
tourni(|uet  in,  .303. 
Incision,  how  made,  .33,  34. 
Incisions  in  ligation,  235,  236. 
Indolent  granulation-,  75. 
Inferior  maxilla,  resection  of,  139. 
fracture  of,  81. 
shot  fracture  of,  97. 
Inferior  dental  nerve,  resection  of,  296. 
Intlainmations,  acute,  65. 
carbunculous,  315. 
chronic,  65. 

conditions  favoring,  63. 
forms  of,  63-65. 
erysipelas.  64. 
erysipelatous,  314. 
erythema,  63. 
in  repair  of  wounds,  6.3. 
of  bladder,  509. 
bone,  106. 
osteo-myclitis,  107. 
periostitis,  106. 
brain,  283. 
breast,  585. 
bursjE,  198,  199. 
joints,  154. 
parenchymatous,  154. 
purulent,  154. 
serous,  154. 
meninges,  283. 
muscles,  196. 
nail,  acute,  .322. 
chronic,  322. 
nerves,  289. 
tendons,  196. 
phlegmonous,  316. 
scrotal,  545. 
septic,  64. 
Inflammatory  fever,  66. 
Infra-orbital  nerves,  anatomy,  294. 
section,  intra-buccal,  294. 
cutaneous,  295. 
Ingrowing  nail,  323. 
Inguinal  hernia,  442. 
Inhalations,  apparatus  for,  473. 

formuhe  for,  473. 
Inhaler,  473. 


674 


INDEX. 


Injections,  hypodermic,  331. 
in  aneurism,  222. 
intravenous  of  milk,  271. 
of  brand}-  in  collapse,  38. 
of  milk,  38. 
rectal,  407,  408. 
Injuries,  of  bladder,  507. 
of  bones,  80. 

circulator}'  system,  213,  220. 
joints,  147. 
muscles,  193. 
nervous  svstem,  275. 
penis,  555. 
prostate  gland,  552. 
tegumentary  svstem,  302. 
thorax,  491. 
urethra,  533. 
Innominate  artery,  anatomy,  238. 
aneurism  of,  237. 
ligation  of,  238,  239. 
relations  of  the,  2-38. 
Instruments,  14. 
case  of,  15. 

for  resection,  113-116. 
material  of,  15. 
preservation  of,  15. 
tests  for,  15. 

to  operate  on  tongue,  368. 
trephining,  145. 
Insufflators,  4G0,  461. 

laryngeal,  473. 
Intermediary  ha;morrhage,  60. 
Internal  pudic  artery,  anatomy,  259. 
ligation  of,  259. 
methods,  259,  260. 
cutaneous  nerve,  298. 

exposure  of,  299. 
resection,  299. 
section,  299. 
Intestines,  gunshot  wounds  of,  89-391. 
intussusception,  392,  399. 
obstruction,  395. 
strangulation,  394. 
large,  wounds  of,  400. 
Intussusception,  ciccal,  399. 
of  jejuniun  and  ileum,  392. 
aspiration  in,  .393. 
laparotomy  in,  394. 
Inversion  in  narcosis,  35. 


Issues,  329. 

by  caustic,  3.30. 
incision,  330. 
moxa,  331. 
seton,  329. 

Jaw,  anchylosis  of  lower,  649. 
Jejunum,  intussusception  of,  392. 
obstruction  of,  395. 
strangulation  of,  394. 
wounds  of,  389,  390. 
Joints,  description  of,  147. 
diseases  of,  154. 
caries,  156. 

fungating,  156. 

simple,  156. 
excision  of,  168. 
inflammation,  154. 
loose  bodies,  167. 
origin  of,  154 

operations  and  injuries  of,  147, 168. 
special  operations,  154. 
wounds  of,  147. 

contused,  147. 

incised,  147. 

lacerated,  147. 

punctured.  147. 
Judgment,  good,  what  constitutes,  3. 

Key  for  compression,  20. 
Kidne\'s,  abscess  of,  498. 
anatomy  of,  497. 
calculus  of,  499. 
extirpation  of,  502. 
rupture  of,  497. 
Knee,  dislocations  of,  153. 

braces,  160. 
Knee-joint,  amputation  of,  626,  627. 
anatomy,  182. 
anchylosis  of,  643. 
caries  of,  160. 
excision  of,  182. 

after-treatment,  186. 
indications,  183. 
methods,  184,  185. 
subperiosteal,  185. 
mortality  after,  182. 
results  of,  183. 
Knife,  31. 


INDEX. 


675 


Knife,  amputation,  592. 

lan'iifjcal,  47'.(. 

nianipiilatioii  of,  32 

paring  for  palate,  351. 

position  of,  32. 

resection,  113. 

staphylorrhaphy.  351. 

tiMiotonn',  203. 
Knot,  in  ligation  of  arteries,  237. 

sailor's,  22. 

surgeon's,  22. 
Knowledge  required,  2. 

Labia,  adhesion  of,  57G. 

hypertrtiphy  of,  577. 

thrombus  of,  577. 
Laceration  of  perineum,  578. 

through  anal  sphincter,  582. 

scrotal,  545. 

of  urethra,  533. 

of  rectum,  409. 
Lacerated  wounds,  305. 
Laparotomy,  394,  39fi,  400. 
l>«paro-elytrotomy,  570. 
Laparo-hysterotomy,  570. 
l.KTryn.K,  abscess  of,  482. 

anatom_v  of,  470. 

burns  and  scakls  of,  478. 

bursal  tumors  of,  483. 

examination  of,  471. 

extirpation  of,  481,  482. 

foreign  bodies  in,  475. 

fracture  of  cartilages  of,  474. 

growths  of,  478. 
malignant,  480. 
non-malignant.  478. 

medication  of,  472. 

obstruction  of,  484. 

adema  of,  477. 

wounds  of,  473. 
Laryngeal  atomizer,  473. 

bistoury,  480. 

brush,  473. 

canula,  476. 

caustic  holder,  472. 

cutting  ring,  477. 

growths,  478,  480. 

insufHator,  473. 

knives,  479. 


Laryngeal  mirror,  471. 
obstruction,  484. 
probang,  474. 
reflector,  472. 
scarificator,  477. 
scissors,  479. 
syringe,  474. 
tampon-cauula,  470. 
Laryngotoniy,  476. 
Lateral  liihotomy,  522. 
after-treatment,  .526. 
indications  for,  522. 
instruments  for,  522. 
operation  of,  522. 
risks  in,  525. 

rules  to  be  observe<l  in,  524. 
Leech,  artificial,  273. 
Leeching,  272. 

artilicial,  273. 
Leg,  amputation  of,  624,  626. 
artificial,  059. 
paralysis  of,  055,  656. 
Legal  construction  of  obligation,  1. 
Ligation,  21. 

of  arteries,  233. 
aperture  of  sheath,  230. 
dissection,  2-36. 
incision,  2-36. 
instnnnents,  233. 
ligatures,  234. 
application  of,  237. 
constricti(U),  2-37. 
location  of,  235. 
needle  passage  of,  237. 
of  aorta,  abdominal,  257. 
axillary,  249. 
brachial,  251. 
carotid,  common,  2.39. 
external.  242. 
internal,  242. 
dorsalis  pedis,  268. 

penis,  260. 
epigastric,  26L 
facial,  243. 
femoral,  262. 
gluteal,  259. 
innominate,  238. 
iliac,  common,  257. 
external,  260. 


676 


INDEX. 


Ligation  in  aneurism,  223,  233. 
points  of,  224,  235. 
of  iliac,  internal,  258. 
lingual,  242. 

mammary,  internal,  245. 
occipital,  244. 
peroneal,  2G8. 
popliteal,  264. 
piidic,  internal,  259. 
sciatic,  259. 
subclavian,  239,  247. 
temporal,  244. 
thyroid,  inferior,  246. 
superior,  242. 
tibial,  anterior,  267. 
posterior,  265. 
ulnar,  254. 
vertebral,  245. 
operation  for  the,  235. 
precautions,  235. 
preparations,  234. 
rules  for  head,  neck,  237. 
for  lower  limb,  256. 
upper  limb,  246. 
wound,  closure  of,  237. 
Ligatures,  in  aneurism,  235,  237. 
application  of,  21. 
for  compression,  21. 
silk,  21. 
hemp,  22. 
catgut,  22. 
Limbs,  artificial,  656,  659. 

dangle,  656. 
Limited  torsion,  23. 
Lingual  nerve,  anatomy,  295. 
artery,  ligation  of,  242. 
methods,  243. 
resection,  296. 
Lips,  acquired  defects  of,  344. 
congenital  defects  of,  340. 
hypertroplw  of,  343,  344. 
wounds  of,  340. 

operations   for    reconstruction    of, 
344,  350. 
Lister's  method,  42. 
Lithotomy,  bilatei'al,  531. 
forceps,  523. 
lateral,  522. 
median,  520. 


Lithotomy,  medio-lateral,  521. 

scoop,  523. 

staffs,  519,  .520,  522. 

supra-pubic,  526. 
Lithotrity,  dangers  of,  514. 

operation  of,  515,  516. 

ordinary,  513. 

perineal,  518. 

preparative  measures,  515. 

rapid,  517. 

rules  to  be  observed,  516. 
Lithotrite,  Bigeli>w's,  514. 

Thompson's,  512. 
Lithotomes,  522. 
Litholapaxy,  522. 

evacuating  apparatus  for,  517. 

operation  of,  518. 
Lithoclast,  519. 
Liver,  abscess  of,  426. 

anatomy  of,  426. 

gall  stones  in,  429. 
Local  anresthesia,  30. 

by  carbolic  acid,  30. 
ether,  30. 
ice,  30. 
Loose  bodies  in  joints,  ]67. 
Lungs,  anatomy  of,  490. 

concussion  of  the,  494. 

hffimorrhage  from  the,  495. 

hernia  of  the,  495. 

puncture  of  cavities  in,  496. 

wounds  of  the,  494. 
gunshot,  494,  499. 
Lymphangitis,  after  wounds,  64. 
Lymphatics,  wounds  of,  218. 
Lupus,  318. 

exedens,  318. 

exfoliatus,  318. 

exulcerans,  318. 

fungosus,  318. 

hypertrophicus,  318. 

origin,  318. 

symptoms,  318. 

treatment,  319. 

Mammary  artery,  ligation  of,  245. 
glands,  585. 

abscess  of  the,  586. 
extirpation  of  the,  588. 


INDEX. 


677 


Mammary  glands,  inflammation  of  the, 
585. 
scirrlius  of  tiie,  587. 
tumors  of  the,  587. 
Manipulation  of  knife,  32. 

in  aneurism,  222. 
Mastitis,  585. 

Material  for  instrument,  14. 
Meatus,  contraction  of,  538. 

imperforate,  529. 
Meatoscope,  529. 
Median  Iithotom\-,  520. 

instruments  for,  520. 
operation  of,  520. 
nerve  resection  of,  299. 
Medication,  nasal,  459. 
of  hirynx,  472. 
by  oesophagus,  377. 
by  the  stomach,  381. 
Medio-lateral  lithotomy,  521. 

operation  of,  521. 
Meningocele,  28G. 
seat,  287. 
treatment,  287. 
Metacarpal  bones,  resection  of,  118. 
methods,  118-120. 
mortality,  118. 
amputations  of,  603. 
disarticulations  of,  603,  606. 
Metacarpal  joints,  excision  of,  169,  179. 
Metacarpus,  shot-fi'acture  of,  98. 
Metatarsal  bones,  amputation  in,  616. 
disarticulation  of,  616,  618. 
resection  of,  131. 
methods,  131. 
Metatarsal  joints,  excision  of,  179. 
Milk,  intravenous  injection  of,  271. 
Mirrors,  rhinoscopic,  458. 
Month  for  operations,  13. 
Morlilication  of  scrotum,  546. 
Mouth  gag.  351. 
Movable-back  saw,  11.5. 
Moxas,  application  of,  331. 
Muscles,  general  operations  on,  202. 
incised  wounds  of,  194. 
injuries  of.  193. 
ruptures  of,  193. 
spasms  of  in  wounds,  70. 
special  operations  on,  193,  196. 


Muscular  system,  diseases  of,  196. 

bur-^ic.  198.  199. 

contracticui,  199. 
of  fascia,  200. 
of  tendon,  200, 

inflammation  of,  19G. 
of  tendons,  196. 

injuries  of,  193. 

special  operations  on,  193,  196. 
Musculo-spiral  nerve,  299. 

anatomy,  299. 

resection,  2it9. 
Musculo-cutaMc<iiis  nerve,  298. 

anatomy,  298. 

resection,  298. 
Myositis,  196. 
M3otomy,  202. 

Naeviis,  cutaneous.  231. 
Nails,  atrophy,  322. 

claw-like,  324. 

hypertrophy  of,  .322. 

horny  growths  of,  324. 

intlammation  of,  322. 

ingrowing,  323. 

onychia,  .323. 

psoriasis  of,  324. 
Narcosis,  34. 

death  from,  35. 

important  symptoms,  34. 

profound,  35. 

slight,  -35. 

symptoms,  35. 

treatment,  35. 
Nasal  fossje,  anatomy  of,  457. 

abscess  of,  464. 

cancer  of,  469. 

clamp  for,  462. 

douches  for,  460. 

ha-morrhage  from,  462. 

insufflators,  4(!0,  461, 

medication  of,  459. 

nn'rrors  for,  458. 

polypi  of,  465. 

specula  for,  457. 

sprays  for,  459. 

stenosis  of,  462. 
Nativity  in  prognosis,  7. 
Necrosis  of  bone,  109. 


678 


INDEX. 


Xecrosis  of  bone,  partial,  109. 
pathology  of,  109. 
•   total,  110. 
Negligence,  what  constitutes,  3. 
Nephritic  abscess,  498. 
Nerves,  compression  of,  ^S^Z. 
contusion  of,  282. 
lesions  of,  282. 
neurectomy,  29-3. 
neurotomy,  292. 
operatioiK  on,  29.3. 
resection  of,  293. 
section  of,  293. 
stretching  of,  29-3. 

when  justifiable,  293. 
wounds  of,  283. 
ulceration  of,  289. 
Nervous  system,  anatomy  of,  27.5. 
abscess  of  brain,  28.5. 
affections  following  wounds,  70. 
constitution,  291. 
delirium  nervosum,  71. 
delirium  tremens.  71. 
encephalot-ele,  287. 
general  operations  on,  291. 
the  brain,  291. 
the  nerves,  29-3. 
the  spinal  cord,  293. 
hernia  cerebri,  285. 
hydrocephalus,  285. 
inflammation  of  brain,  28.3. 

of  nerves,  289. 
injuries  of,  275. 
compression  of  brain,  276. 

of  nerves,  282. 
concussion  of  brain,  275. 

of  spine,  278. 
contusion  of  brain,  276. 

of  nen-es.  282. 
fissure  of  skull,  277. 
fractures  of  skull,  277,  278. 

of  spine,  280. 
sprains  of  spine,  279. 
wounds  of  brain,  277. 
meningocele,  286. 
neuralgia,  290. 
neuromata,  289. 
pain,  70. 
spina  bifida,  288. 


Nervous  system,  si\bcutaneous  tuber- 
cles, 289. 

spasms  of  muscles,  70. 

tetanus,  72. 

ulceration  of  nen-es,  289. 
Neuralgia,  290. 

causes,  290. 

dissection  of  nerves  in,  290- 

of  dental  nerves,  290. 
Neurectomy,  293. 
Neuritis,  289. 
Neuromata,  289. 
Neuromimesis,  291. 
Neurotomy,  293. 
Nipple,  chronic  affection  of,  587. 
Nitrous  oxide,  27. 
Nose,  abscess  of,  -164. 

cancer  of,  469. 

foreign  bodies  in,  464. 

imperforate,  461. 

occlusion  of,  401. 

operations  on,  455. 

papilloniata  of,  464. 

polypi  of  the,  465,  467. 

sarcomata  of,  469. 

tumors,  cartilaginous  of,  468. 
osseous  of,  468. 
Nostrils,  occlusion  of,  461. 
Nurse,  16. 

Obligation,  civil,  1. 

professional,  1. 

legal  construction  of,  1. 
Obstruction,  intestinal,  395. 

causes,  395. 

laparatomy  in,  .396. 

treatment,  -395,  396. 
Occipital  artery,  ligation  of,  244. 
Occlusion  of  nostrils,  461. 
Odontomes,  359. 
(Edema  of  larynx,  477. 
CEsophageal  forceps,  378,  379. 

probang,  377. 
(Esophagotomy,  380. 
Oesophagus,  anatomy  of,  377. 

catheterism  of  the,  378. 

foreign  bodies  in  the,  378. 

medication  through  the,  377. 

resection  of  the,  381. 


INDEX. 


679 


CEsophagas,  stricture  of  the,  380. 
Office,  operations  in,  13. 
Olecranon   process,  fracture  of,  87. 

treatment  of,  88. 
Onychia,  323. 
Operations,  age  in,  7. 
arrangements  for,  17. 
cellulitis  after,  9. 
conclusion  as  to,  31. 
consent  to,  11. 
constitutional  diseases  in,  7. 
effect  of  intemperance  on,  8. 
effect  of  over-eating  on,  8. 
erysipelas,  after,  9. 
external  conditions,  9. 
for  hernia,  441. 
phymosis,  5.56. 
vesico-vaginal  fistula,  574. 
general,  on  bones,  111. 
on  joints,  168. 

nervous  system,  291. 
muscles,  202. 
circulatory  system,  232. 
arteries,  233. 
capillaries,  272. 
heart,  232. 
veins,  269. 
in  acute  inflammation,  9. 
influence    of   abdominal    plethora, 
8. 
affections  of  heart,  9. 
ana?mia,  8. 

degeneration  of  arteries,  9. 
diseased  veins,  9. 
disea.*e  of  lungs,  9. 
dyspepsia,  8. 
enlarged  liver,  8. 
kidney  diseases,  9. 
menstruation  and  pregnancy,  9. 
nervous  affections,  9. 
rheumatism  and  gout,  7. 
scrofula,  7. 
shock,  9. 

strumous  affection,  9. 
syphilis,  7. 
of  castration,  551. 
laryngotomy,  470. 
thyrotomy,  475.  477. 
tracheotomy,  475,  484. 


Operations,    on    tegunientarv    svstem, 
302.  313,  325. 
result  of,  31. 
rhinoplastic,  455,  456. 
special,  on  bones,  101. 
on  circulatory  system,  213,  220. 
joints,  147,  154. 
muscles,  19.3,  196. 
nervous  system,  275,  283. 
when  justifiable,  10. 
Orchitis,  syphilitic,  550. 
Osteotomy,  635. 
Osteoclast,  635. 
j  Osteoplasty,  146. 
I  Osteo-myelitis,  107. 

Os  calcis,  resection  of,  133. 
I  Ovarian  cyst,  561. 

inflammation,  559. 
trocars,  561,  563,  564. 
Ovaries,  anatomy  of,  559. 
c^'stic  tumors  of,  561. 
inflammation  of,  559. 
removal  of,  560. 
tapping  the,  561,  502. 
Ovariotomy,  affusion  after,  565. 
clamp,  564. 
operation  of,  563. 
preliminary  measures,  563. 
trocars,  503,  564. 
Ovaritis,  559. 

operative  treatment,  560. 

Pain  in  woimds,  70. 
Palate,  anatomy,  350. 
cleft,  .351.  " 
operations  on  the,  .352,  354. 

instruments  for,  351. 
soft,  contraction  of,  356. 
Papillomata,  nasal,  464. 
Paracentesis  thoracis,  492. 

indications  for,  492.  493. 
instruments  for,  492. 
methods,  493. 
of  pericanlium,  233. 
Paralysis,  appliances  for,  654,  656. 
Paraphymosis,  556. 
Parenchymatous  luemorrhatre,  61. 
Parotid  gland,  anatomy,  362. 
abscess  of  the,  363. 


m 


INDEX. 


Parotid  gland,  calculi  of  the,  363. 

extirpation  of  the,  3G5. 

fistulre  of  the,  363. 

tumors  of  the,  364. 

wounds  of  the,  362. 
Patella,  fracture  of,  91. 

dislocation  of,  153. 

non-united  fracture  of,  652. 

resection  of,  136. 
Patient,  preparation  of,  11. 
Penis,  amputation  of,  558. 

anatomy  of,  555. 

cancer  of  the,  557. 

circumference  of,  529. 

extirpation  of,  558. 

injuries  of  the,  555. 
Perineal  liihotrity,  518. 

indications  for,  518. 
instruments  for,  518. 
operation,  519. 

nerve,  resectic)n  of,  300. 
Perineorraphy,  579,  580,  583. 
Perinephritic  abscess,  498. 
Perineum,  laceration  of,  578,  582. 

operative  methods,  579,  580,  583. 
Periosteotome,  113,  351. 
Periostitis,  106. 

Peroneal  artery,  ligation  of,  269. 
Peroneal  nerve,  resection  of,  300. 
Phagedena  in  repair  of  wounds,  62. 
Phalanges,  amputation  of,  599,  600. 

dislocation  of,  151. 

distortion  of,  634,  642. 

flexion  of  joints  of,  634. 

resection  of,  118,  130. 

shot  fracture  of,  98. 

supernumerary,  633. 

webbed,  6-33. 
Phalangeal  joints,  anchylosis  of,  642. 

excision  of,  169,  179. 
Pharj'nx,  abscess  of,  376. 

anatomy  of,  375. 

foreign  bodies  in,  376. 

inspection  of,  375. 

wounds  of,  376. 
Pharyngeal  abscess,  376. 

mirror,  375. 
Phimosis,  555. 

operation  for,  556. 


Phlegmonous  inflammation,  316. 
Physical  examination,  6. 
Place  for  operations,  13. 
Plantar  nerve,  internal,  301. 

anatomy  of,  301. 

resection  of,  301. 
Plastic  apparatus,  53,  81. 

bandages,  81. 
objections  to,  81. 

gypsum  splint,  54. 

silica  bandage,  54. 

starch  bandage,  54. 
precautions  needed,  53. 
shears  for  cutting,  55. 
Pleura,  wound  of,  491. 

collection  of  pus  in,  496. 
Pneumocele,  495. 
Poisoned  wounds,  310. 
Polypus  forceps,  405. 

snare,  466. 

rectal,  413. 
treatment,  414. 

uterine,  508. 
Polypi  of  the  tongue,  370. 

nasal,  465,  467. 
Popliteal  artery,  anatomy  of,  264. 
aneurism  of,  257. 
treatment,  257. 
ligation  of,  264. 

methods,  264,  265. 
wounds  of,  217. 

nerve,  resection  of,  300. 
Position  of  wounds,  41. 
Preparation  of  patient,  11. 
Preservation  of  instruments,  15. 
Principles  of  an  art,  1. 
Probang,  laryngeal,    474. 
Probangs,  377. 
Prognosis,  age, in  7. 

constitutional  diseases  in,  7. 

deranged  conditions  of  organs 

habits  and  temperament  in,  8. 

nativity  in,  7. 

other  affections  in,  9, 

sex  in.  7. 
Progress  of  disease,  6. 
Prolapse  of  rectum,  412. 

treatment,  112. 
Prostate  gland,  anatomy,  552. 


INDEX. 


681 


Prostate  gland,  hypertrophy  of,  552. 
catlieterisiin  in,  553,  554. 
diagnosis  of,  55-3. 

injuries  of  the,  552. 
Prostatic  catheters,  554. 

guide,  555. 
Pytemia,  causes,  68. 
Py»niic  fever,  68. 
Pseudarthrosis.  650. 

drill  in,  6.50. 

friction  in,  650. 

resection  in,  651. 

section,  subcutaneous  in,  651. 
Psoriasis  of  nails,  324. 

Qualifications  of  surgeon,  2. 
knowledge,  degree  of,  2. 
limit  to,  2. 


lowest  grade  of,  2. 


Radial  artery,  wounds  of,  216. 
ligation  of,  25;<. 
methods.  253,  254. 
nerves,  resection  of,  299. 
Radius,  fracture  of,  85. 
elucidation  of,  85. 
and  ulna,  fracture  of.  88. 
and  ulna,  resection  of,  124. 
non-united  fracture  of,  651. 
resection  of,  120. 
after-treatment,  120. 
methods,  121. 
mortality.  120. 
shot  fracture  of.  97. 
Ranula,  trea'mcnt  <>f,  .370. 
Rapid  respiration,  30. 
Reconstruction  of  lips,  344,  350. 
Rectal  abscess,  409. 
cancer,  415. 
dilatos,  402. 
exploration,  405,  406. 
medication.  407. 
polypus,  413. 
prolapse,  412. 
specula?,  406,  407. 
stricture,  416. 
syringes,  407. 
Rectotomy,  411,  412. 
Rectum,  abscess  near,  409. 


Rectum,  absence  of,  409. 
alimentation  by,  408. 
anatomy  of  the.  405. 
cancer  of  the,  415. 
e.\ploration  of  the,  405,  406. 
extirpation  of,  415. 

with    prostate  and  base   of  the 
bladder,  416. 
foreign  bodies  in,  414. 
imperforate,  408. 
laceration  of,  409. 
medication  by,  4<i7. 
polypus  of  the,  413. 
prolapse  of,  412. 
speculae  for.  406.  407. 
stricture  of,  410. 
Refracture  of  bones,  634. 
Refrigerator,  30. 
Renal  abscess,  498. 

calculi,  499. 
Repair  after  operations.  56. 
antiseptic  method  in,  58. 
complications  of,  60. 
ditTerent  irtatnient  in.  58. 
fevers  during,  57,  65. 
gangrene  during,  61. 
ha>morrhage  during.  60. 
hot-water  dressing  in,  59. 
indications  of,  56. 
inflammations  in,  63. 
nervous  affections  in,  70. 
normal,  57. 

ordinary  dressings  in,  58. 
pulse  in,  57. 
wound  changes  in,  57. 
Resection,  112. 

indications,  112. 
instruments,   112-116. 
of  bones,  112. 
astragalus.  133. 
clavicle.  128. 
coccyx,  137. 
cuboid,  132. 
cuneiform,  132. 
femur,  136. 
fibula,  134. 
humerus,  124. 
inferior  maxilla,  139. 
metacarpal  bones,  118. 


682 


INDEX. 


Kesection  of  metatarsal  bones,  131. 

OS  calcis,  133. 

patella,  136. 

phalanges  of  lingers,  118. 

phalanges  of  toes,  130. 

radius,  120. 
and  ulna,  124. 

ribs,  138. 

sacrum,  137. 

scaphoid,  133. 

scapula,  127. 

sternum,  138. 

superior  maxilla,  142,  145. 

tarsal,  132. 

tibia,  135. 

ulna,  122. 

vertelira^,  137. 
of  nerves,  2;)3. 

indications,  293. 

rules  203. 

brachial  plexus,  297. 

cutaneous,  internal,  298. 

dental  inferior,  296. 

digital,  299. 

lingual,  296. 

median,  299. 

musculo-cutaueous,  298. 

nuisculo-spiral,  299. 

perineal,  300. 

peroneal,  300. 

plantar,  internal,  301. 

popliteal,  300. 

radial,  299. 

saphenous,  external,  301. 
internal,  301. 

sciatic,  great,  300. 
small,  300. 

supra-maxillary,  295. 
orbital,  294. 

tibial  anterior,  300. 
posterior,  300. 

ulnar,  299. 
of  oesophagus,  381. 
operation  of,  116. 
time  for,  112. 
treatment  of  wounds,  117. 
Respiration,  artificial,  35,  36. 
Responsibility  in  operations,  4. 
Resuscitation  in  narcosis,  35. 


Retention  of  urine,  511. 
Retractors,  113. 
Retro-pharyngeal  abscess,  376. 
Retroversion  of  uterus,  567. 

repo-itor  for,  568. 
Rhinoplasty,  455. 

operative  methods,  455,  456. 
Rhinoscopy,  458. 

instruments  for,  458. 
Rhinoscope,  458. 

Ribs  and  cartilages,  fracture  of,  82. 
complications,  82. 
treatment,  101. 
resection  of,  138. 
methods,  138. 
Rickets,  treatment  of,  101. 
Rings,  elastic,  19. 
Room  for  convalescent,  16. 

for  operating,  13. 
Rubefacients,  327,  328. 

action  of,  327. 
Ruptures  of  arteries,  214. 
of  bladder,  507. 
kidney,  497. 
muscles,  193. 
spleen,  430. 
tendons,  194. 

Sacrum,  resection  of,  137. 
Saphenous  nerve,  external,  301. 
exposure  of,  301. 

internal,  resection  of,  301. 
Sarcomata,  104. 

of  skin,  320. 

nasal,  469. 
Sarcoma  of  testicle,  551. 
Saw,  chain,  114. 

circular  edge,  115. 

curved,  115. 

movable  back,  115. 

oval,  351. 

spring,  115. 

straight,  115. 

subcutaneous,  648. 
Scalds,  312. 

cicatricial  contractions  in,  313. 

degrees,  312. 
Scaphoid  bone,  resection  of,  133. 
Scapula,  resection  of,  127. 


INDEX. 


683 


Scapula,  methods  of  resection,  127,  128. 
Scarification,  273. 
Sciatic  artery,  ligation  of,  259. 
nerve,  great,  300. 

resection  of,  300. 
nerve,  small,  resection  of,  300. 
Scissors,  curved,  574. 
for  tonsils,  36G. 
for  vulva,  357. 
laryngeal,  479. 
Scoop,  litliotoniy,  523,  525. 
Scrotum,  cancer  of,  547. 
contusion  of,  545. 
elephantiasis  of  the,  'AG. 
hydrocele  of,  547. 
intiamniatiun  of  the,  545. 
lacer.it ion  of  the,  545. 
mortification  of  the,  54G. 
varicocele,  547. 
Secondary  htemorrhage,  60. 
Section  of  nerves,  293. 
indications  for,  293. 
of  brachial  plexus,  297. 
cutaneous  internal,  298. 
dental  inferior,  29C. 
digital,  299. 
lingual,  290. 
median,  299. 
musculo-cutaneous,  298. 
musculo  spiral,  299. 
perineal,  300. 
peroneal,  300. 
plantar  internal,  -301. 
popliteal,  .300. 
radial,  299. 
saphenous,  external;  .301. 

internal,  301. 
sciatic,  great,  300. 

small,  .300. 
supra  maxillary,  295. 
supra-orbital,  294. 
tibial,  anterior,  300. 

posterior,  300. 
ulnar,  299. 
rules,  293. 
Ctesarean,  570. 
Septica>mia,  67. 
§eptic  fever,  67. 

inflammation  in  wounds,  64. 


Seiiuestrotomy,  111. 
direct  metho<l.  111. 
j  indirect  method,  HI. 

!  Setons,  application  of,  329,  330. 
I  Sex  in  prognosis,  7. 
I  Shock,  .37. 

severity  of,  37. 
Shot  fractures,  96. 
of  clavicle,  97. 
femur,  99. 
humerus,  97. 
inferior  ma.xilla,  97. 
metacarpal  bones,  98. 
phalangeal  bones,  98. 
radius  and  ulna,  97. 
superior  maxilla,  90. 
tibia  and  fibula,  100. 
varieties,  90. 
Shoulder  joint,  anchylosis  of,  643. 
amputation  of,  611. 
by  double  flap,  613. 
oval  method,  <!1 1. 
single  Hap,  612. 
Shoulder,  dislocation  of,  149. 
compound,  150. 
reduction  of,  1.50. 
subspinous,  150. 
excision  of,  176. 
indications,  177. 
methods,  178. 
mortality  from,  177. 
results  of,  177. 
subperiosteal,  179. 
treatment  of,  179. 
Silica  ban<lage,  65. 
Silk  ligature,  21. 
Skill,  imjilied,  2. 
Skin,  diseases  of,  313. 
injui'ies  of,  302. 
operations  on,  325. 
transplantation  of,  76,  335. 
Skull,  fissures  of,  277. 

fractures  of,  277,  278. 
Sound,  tunneled,  542. 
vesical,  .503. 
urethral,  529. 
Spasms,  muscular   in  wounds,  70. 
Specula,  vaginal,  572. 
nasal,  457. 


684 


INDEX. 


Specula,  rectal,  406,  407. 
Spermatic  cord,  Jiismatocele  of,  548. 

hydrocele  of,  548. 

varicose  veins  of,  548. 
Spina  bifida,  288. 
Spine,  caries  of.  162. 

concussion  of,  278. 

fractures  of,  280. 

railway  injuries  of,  279. 

sprains  of,  279. 

trephining  of,  293. 
Spinal  abscess,  166,  167. 

caries,  162. 

apparatus  for,  165,  166. 
Spleen,  anatomy  of,  4-30. 

hypertrophy  of,  430. 

rupture  of,  430. 

wounds  of,  430. 
Splenotomy,  431. 
Splints,  sypsum,  81,  88,  92-94. 

for  hip-joint  disease,  159. 
application  of,  '59. 

jijypsnm  for  hip,  192. 
Sprains  of  spine,  279. 
Sprays,  nasal,  459. 
Spring  saw,  115. 
Staff,  lithotomy,  519,  520,  522. 
Staphylorraphy,  352. 

knife,  351. 

operative  methods,  352,  353- 

sutm-es  in,  354. 
Starch  bandage,  54. 
Stenosis,  nasal,  462. 
Sterno-clavicular  dislocation,  149. 

reduction,  149. 
Sternum,  resection  of,  138. 
Stomach,  anatomy  of,  381. 

alimentation  by  tistula  of,  382. 

foreign  bodies  in,  387. 

pumps,  .381. 

wound  of  the,  386. 
Straight  saw,  115. 
Strangulation  of  intestines,  394. 
Stretching  of  nerves,  29-3,  294. 
Stricture  of  colon,  401. 
dilatation  of,  402. 
colotomy  in,  403. 
exploration  of,  402. 

of  oesophagus,  379. 


Stricture  of  oesophagus,  dilatation  of, 
380. 
of  the  urethra,  536. 
dilatation  of,  539. 
.     division  of,  539,  542. 
divulsion  of,  539,  540. 
location  of,  536. 
permanent,  536. 
recontractioM  of,  539. 
spasmodic,  536. 
sj'mptoms,  536. 
treatment  of,  538. 
varieties  of,  536. 
rectal,  410. 

after  treatment,  412. 
diagnosis,  410. 
dilatation  of.  411. 
incision  of,  411. 
rectotomy  in,  411. 
Subclavian  arteiy,  anatomy,  247. 
aneurism  of,  246. 
direction  of,  247. 
ligation  of,  2.39,  247,  248. 
precautions,  249. 
Sublingual  gland,  362. 
abscess  of,  363. 
calculi  of,  363. 
fistulas  of,  363. 
tumors  of,  364. 
wounds  of,  362. 
Submaxillary  gland,  362. 
abscess  of,  363. 
calculi  of.  363. 
extirpation  of,  365. 
fistulffi  of,  363. 
tumors  of,  364. 
wounds  of,  362. 
Suggillation,  217. 
Superior  maxilla,  resection  of,  142. 
methods,  142-145. 
shot  fracture  of,  96. 
Superior  maxillary  nerve,  295. 
resection  of,  295. 
section  of,  295. 
Supra-orbital  nerve,  anatomy,  294. 
resection,  294. 
section,  294. 
Supra-pubic  lithotomy,  526. 
Suspension  apparatus,  163. 


INDEX. 


665 


Suture  adjuster,  351. 

forceps,  47. 

interrupted,  46. 

materials  for,  47. 

needle,  spiral,  .351. 

needk's  for,  47. 

quilled,  47. 

twisted,  47. 
Syncope:  symptoms,  treatment,  37. 
Synovial  sheaths,  inflauimutiunuf,  l'J7. 
Synovitis,  cliruiiie,  155. 

parenchymatous,  154. 

serous,  154. 
Syringe,  laryngeal,  474. 
Syringes,  rectal,  407. 

Table,  gynaecological,  573. 
Talipes  calcaneus,  0-38. 
equinus,  (J37. 
valgus,  640. 
varus,  636,  6-39. 
Tampon-canula,  laryngeal,  480. 
Tapping  in  ascites,  435. 
the  ovary,  561,  562. 
Tarsal  bones,  dislocations  of,  153. 

resection  of,  132. 
Tarsal  joints,  excision  of,  179. 
Tarso- metatarsal  disarticulation,  618. 
Tarsus,  disarticulation  of,  620. 
Teeth,  extraction  of,  360. 
Tegumentary  .system,  -302,  313. 
acu]>iincture,  329. 
applications,  enderniic,  -328. 
diseases  of,  313. 
acne  rosacea,  .321. 
callosity,  313. 
carbuncle,  315. 
cellulitis,  316. 
corn,  314. 

cutaneons  horn,  314. 
elephantiasis,  319. 
epithelioma.  320. 
erysipelatous  inflammation,  314. 
fibrous  tnninr,  soft,  320. 
furuncle,  315. 
hair,  overgrowth,  320. 
lupus,  318. 
nail,  atrophy  of,  322. 
claw,  324. 


Tegumentary  system,  diseases  of,  — 
nail,  hypertrophy  of,  322. 
horny  growths,  324. 
intlammatiou,  322. 
ingrowing,  323. 
onychia,  323. 
psoriasis,  324. 
retained  secretions,  321. 
sarcomata,  320. 
ulcer,  317. 
warts,  314. 
general  operations  on  the,  325. 
injections,  hypodermic,  331. 
injuries  of,  302. 
burns,  312. 
chilblains,  311. 
contusion,  302. 
frost  bite,  311. 
scalds,  312. 

wounds,  contused,  305. 
incised,  303. 
gunshot,  .305. 
lacerated,  305. 
poisoned,  310. 
issues  in,  329. 

operations  on,  .302,  313,  325. 
rul>efacients,  327. 
thermometry,  325. 
transplantation  of  skin,  335. 
vaccination,  332. 
vesicants,  .328. 
Telangiectasis,  231. 
Temporal  artery,  ligation  of,  244. 
Temporo-ma.xillary  dislocation,  148. 
Tenacuhnn,  21. 
forceps,  21. 
for  tonsil,  .366. 
Tendons,  contraction  of,  20. 
inflammations  of,  196. 
rupture  of,  194. 
causes,  194. 

of  biceps  flexor  cubiti,  195. 
quadriceps  extensor,  195. 
tendo-.Vchillis,  195. 
triceps  extensor  cubiti,  195. 
woimds  of,  195. 
Tendo-.\chillis,  division  of,  209. 
Tenotomy,  20. 

after-treatment  of,  204. 


686 


INDEX. 


Tenotomj^  discrimination  in,  202. 
indications  for.  202. 
instruments  for,  203. 
of  adductor  longus,  210. 
biceps  flexor  cruris,  209. 

cubita,  206. 
deltoid,  206. 
extensor  longus  digitoruni,  207. 

proprius  poliicis,  207. 
extensors  of  fingers,  205. 
flexor  carpi    radialis,  205. 

ulnaris,  205. 
flexors  of  fingers,  204. 
gracilis,  210. 

latissimus  dorsi,  207,  212. 
longissimus  dorsi,  211. 
longus  digitoruni,  207. 

poliicis,  207. 
multifidus  spinae,  211. 
palmaris  longus,  206. 
pectineus,  210. 
pectoral  is  major,  206. 
peroneus  brevis,  209. 
longus,  209. 
fertius,  209. 
quadriceps  extensor,  210. 
sacro-lunibalis,  211. 
sartorius,  210,  211. 
semi-membranosus,  210. 
semi-tendinosus,  210. 
sterno-cleido  mastoid,  212. 
tendo-Achillis,  209. 
tensor  vaginas  femoris,  211. 
teres  major,  207. 
thumb,  205. 
tibialis  anticus,  208. 

posticus,  208. 
trapezius,  212. 
triceps  extensor  cubiti,  206. 
operation  of,  203. 
Tenotomes,  203. 
Testicles,  545. 

cancer  of  the,  551. 
ep'didymitis,  549. 
extirpation  of,  551. 
haematocele  of,  549. 
orchitis,  550. 
sarcoma  of,  551. 
tubercles  of,  551. 


Tests  for  instruments,  15. 
Tetanus,  symptoms,  treatment,  72. 
Thermo-cautery,  25. 
Thermometers,  325. 

uses  of,  325,  326. 

varieties  of,  325. 
Thermometry,  325. 

rules  for  application,  325,  326. 
Thermoscope,  327. 
Thigh,  amputation  of,  628. 

by  antero-posterior  tiaps,  629. 

by  lateral  flajw,  629. 

artificial,  659. 

paralysis  of,  655. 
Thorax,  foreign  bodies  in,  492. 

injuries  of  the,  491. 

tapping  the,  249. 
Thrombosis,  arterial,  220. 

venous,  225. 
Thrombus  of  labia,  577. 
Thumb,  amputation  of,  602. 
Th^'roid  gland,  anatomy'  of,  488. 

arteries,  ligation  of,  246. 
inferior,  246. 
superior,  246. 

excision  of,  489. 

hypertrophy,  488. 

wounds  of,  488. 
Thyrotomy,  477,  479. 
Tibia,  amputation  of,  623. 

fracture  of,  92. 
treatment,  92. 

ligaments  of,  135,  136. 

methods,  135. 

non-united  fracture  of,  652. 

resection  of,  135. 
Tibia  and  fibula,  fracture  of,  93. 

shot- fracture  of,  100. 
Tibial  arteries,  wounds  of,  216. 

artery,  anterior,  ligation  of,  207. 
methods.  267,  268. 

artery,  posterior,  ligation  of,  265. 
methods,  265,  266. 

nerves,  resection  of,  300. 
Time  for  operations,  12. 
Toes,  artificial,  658. 

amputations  of,  614. 

disarticulations  of,  614,  615. 
Tongue,  abscess  of,  370. 


INDEX. 


687 


Tongue,  cancer  of,  372. 

depressor,  375. 

extirpation  of,  373,  374. 

forceps,  357. 

hypertmiihy  of,  370. 

instruments  to  operate  on,  368. 

oedema  of,  370. 

polypi  of,  370. 

-tie,  treatment  of,  3G9. 

wounds  of,  370. 
Tonsils,  anatomy  of,  305. 

abscess  of  the,  3GG. 

cancer  of  the,  3fi7. 

exci.sion  of  the,  3GG,  3G7. 

hypertrophy  of  the,  3GG. 

instruments  to  operate  on  the,  3G5. 

serrated  forceps  for,  3GG. 

scissors.  3GG. 

tenaculum  forceps,  3GG. 
Tonsilotome,  366. 
Tooth  tumors,  classification,  359. 
Torsion,  22. 

free,  23. 

limited,  23. 
Tourniquet,  591. 

for  compression,  20. 

application  of,  20. 
Trachea,  anatomy  of,  483. 

exploration  of  the,  483. 

ol)^truction  if  the,  484. 

wounds  of,  483. 
Tracheotomy,  after  treatment,  487. 

instruments  for,  485-487. 

operative  methods,  484,  485. 
Tracheotomes,  483. 
Tracheal  canulas,  486,  487. 

double  hooks,  487. 

forceps,  486,  487. 

obstruction,  484 

trocars,  487. 
Transfusion,  indications,  270. 

methods,  270,  271. 

in  collapse,  .38. 
Transplantation  of  skin,    76,  335. 

indications  for,  335. 

methods,  335. 

by. approximation,  336. 
sliding,  336. 
transfei ,  336. 


Transplantation     of    skin,    operations 
for,  337. 

rules  to  be  observed,  335. 

sutures  in,  336. 
Traumatic  f^angrene,  71. 

fever,  66. 
Trephining,  145. 

method,  146. 

the  cranium.  291. 

the  spine,  293. 
Trephines,  145. 
Trocar,  dome,  5G4. 

ovarian,  561,  563,  594. 
Trusses  for  herniiv,  443,  444. 
Tubercles,  of  testis,  551. 

painful  subcutaneous,  289. 
Tmnors  of  bone,  102. 

characteristics,  102. 

diagnosis  of,  103. 

rules  for  treatment,  103. 

carcinomata,  105. 

chondromata,  103. 

exostoses,  103. 

fibromata,  105. 

sarcomata,  104. 
Tumors,  bursal  of  larynx,  483. 

connective  tissue,  320. 

cj'stic  ovarian,  561. 

malignant  of  larynx,  480. 

nasal,  468. 

non-malignant,  478. 

of  abdominal  walls,  434. 

of  breast,  587. 
removal  of,  588. 
soft,  fibrous,  .320. 

of  salivary  glands,  364. 
nature,  364. 

operations  for  removal,  364,  365. 
seat,  .364. 

of  tooth,  359. 

Ulcer,  317. 

callous,  318. 
erelhitic,  317. 
fungous,  317. 
treatment,  317,  318. 
Ulna,  rest'Ction  of,  122. 

methods  of,  122,  123. 
mortality  after,  122. 


688 


INDEX. 


Ulna,  non-united  fracture  of,  651. 
Ulnar  artery,  ligation  of,  254. 
methods,  255,  256. 

artery,  wounds  of,  216. 

nerve,  resection  of,  299. 
Umbilicus,  hsemorrliage  of,  4-34. 

morbid  growths  of,  434. 
Umbilical  growths,  4-34. 

ha?niorrhage,  434. 

hernia,  452. 
Uranoplasty,  354. 

age  for  operating,  354. 

conditions  for  success,  355. 

operation  of,  355. 

preparatory  treatment,  354. 
Urethra,  anatomy  of,  527. 

calculus  of,  533. 

calibre  of,  527. 

exploration  of,  538. 

foreign  bodies  in,  534. 

imperforate,  529. 

laceration  of  the,  533. 

measurement  of,  528. 

prolapsu.s  of, 

stricture  of  the,  536. 

tapping  tlie,  544. 

wounds,  533. 
Urethra-meter,  528 
Urethral  calcuhii*,  533. 

calibre,  527. 

catheterism,  504. 

exploration,  538. 

forceps,  534. 

prolapsus, 

scoop,  535. 

searcher,  535. 

stricture,  536. 

trilabe,  535. 

veins,  varicose,  229. 

wounds,  533. 
Urethrotomes,  542,  543. 
Urethrotomy,  externa!,  543. 

internal,  542. 
Urine,  extravasation  of,  507. 

retention  of,  511. 
aspiration  in,  511. 
Uterine  cancer,  571. 

exploration,  566. 

fibroids,  568. 


Uterine  polj'pi,  568. 

probes,  566. 

repositor,  568. 

sounds,  566. 
Uterus,  anatomy  of,  566. 

cancer  of,  571. 

cervical  constriction  of,  567. 

exploration  of  cavitj-,  566. 

fibrous  tumors  of  the,  568. 

polypus  of  the,  568. 

retroversion  of  the,  567. 
Uvula,  abscess  of,  357. 

elongation  of.  357. 

instruments  for  operating  on,  357. 

scissors,  357. 
Uvulatonie,  357. 

Vaccination,  332. 

age  of  subject  for,  333. 

complications,  834,  335. 

course  of,  334. 

performance  of,  333,  334. 

virus  used,  333. 
Vagina,  exploration  of,  571. 

tumors  of  the,  576. 
Vaginal  fistula,  419,  574. 

operative  methods,  419,  420. 

specula,  572. 
Vaginismus,  572. 
Varices,  225. 

causes,  226. 
Varicocele,  547. 

causes,  229. 

treatment,  229,  230. 
Varicose  veins.  226,  2-30. 

aneurism,  219. 

veins  of  spermatic  corrf,  548. 
Veins,  air  in  the,  38. 

contusion  of,  217. 

ha-morrhoidal,  227. 

internal  saphena,  226. 

spermatic,  229. 

urethral,  229. 

varicose.  226. 

of  spermatic  cord,  548. 
of  urethra,  229. 

venous  nwvi,  230. 

wounds  of   218. 
Venesection,  269. 


/.\I>EX. 


r.89 


Venesection,  from  llip  cejihalii-,  270. 
jii.i,Milar,  27(1. 
inti-riial  sMphi'iia,  270. 

infllic.ds  of,  2»;ii,  270. 
Vciioiis  iian-i,  2W. 

lliroMibosis,  225. 
Veriitifoiin  appcmli.K.  abscess  of,  •'307. 

e.\|.loiali..n  of,  ;JOS. 

operation  for,  3!(8. 

perlorafiKn  of,  397. 
Verruca,  314. 
\'ertebr*,  caries  of,  1G2. 

dislocation  of,  14!). 

reilnclion  of,  149. 

resection  of,  137. 

nietlio.l  of.  137. 

mortality  after,  137. 
Vertebral  artery,  li'xation  of,  24.5. 
methods,  24.5,  24iJ. 

arteries,  wounds  of,  210. 
Vesical  fiecal  listula,  420. 
varieties  of.  421. 

calculi,  512. 
in  Women,  526. 

catheters,  503. 

exploration,  503. 

extroversion,  505. 

inflammation,  50!),  510. 

irrii,'ati>r,  510. 

sounds,  .503. 

wounds,  .508. 
Vesico-vaj;inal  tisfnia,  574. 

ojieration  for,  574,  575. 
Vesicants,  .32S. 

Vocal  apparatus,  arlilicial,  481. 
\'ul<ellum,  357. 
X'ulva,  epithelioma  of,  577. 

laceration  of,  578. 

Ward  for  convalescpnts,  Ifi. 
Warts,  treatment  of,  314. 
Wounds,  contused,  48,  305. 

cleansiu'i;  of,  40. 

disinfection  of,  41. 

drainai^e  of,  41 . 

dressiuEC  of,  39. 

gun-shot,  305. 

gunshot  of  intestines,  3!)1. 

hot-water  treatment,  49. 
44 


WfUiids,  incised,  48,  303. 
of  abdominal  walls,  431. 
pinictured,  4.'!3. 
trealmenl,  431,  433. 
arteries,  215,  216. 
blad.ler,  508. 
brain,  277. 
bursa-,  195. 
ca-cum,  3!»6. 
duodenum,  389. 
gunshot,  391. 
heart,  213. 
ileum,  38!t. 
jejunum.  389. 
joints,  147. 
large  intestine,  400. 
larynx,  47.3. 
lips,  340. 
lungs,  495. 
lymphatics,  218. 
muscles,  194. 
nerves,  283. 
pharynx,  376. 
pleura,  491. 
salivary  glands,  362. 
spleen.  4.30. 
stomach,  .386. 
tendons,  195. 
thoracic  parietes.  491. 
th>Toid  gland,  488. 
tongue,  370. 
trachea,  483. 
urethra.  533. 
veins,  .38.  218. 
open  treatment,  48. 
jiosition  of.  41. 
poisoned,  310. 

[ireparatioii  f<ir  dressing,  40. 
puiictureil,  43. 
union  of,  40. 
Wrist,  excision  of,  lti!i. 

after-treatment,  172. 
indications.  170. 
methods.  170.  172. 
results,  169. 
paralysis  of,  654. 
ili>liU'ation  of,  151. 
joint,  anchylosis  of,  642. 


DUE  DATE 

Printed 
in  USA 

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RD32Sm61881C1 

Manual  of  iti' ji'  ..  i'.l:.'.Lli.', 


2002189020 


